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Take 5 for Safety

Reducing Errors Collider-Accelerator Department 2-16-2010. Take 5 for Safety. No Instructions Or Checklists. A KC-135 Aircraft was being pressurized at ground level

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Take 5 for Safety

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  1. Reducing Errors Collider-Accelerator Department 2-16-2010 Take 5 for Safety

  2. No Instructions Or Checklists • A KC-135 Aircraft was being pressurized at ground level • The outflow valves used to regulate the pressure of the aircraft were capped off during a 5 year overhaul and never opened back up • The technician who, "had always done it that way," was using a pressure gauge with no maximum markings, and no procedure • The rear hatch was blown over 70 yards away, behind a blast fence

  3. No Instructions Or Pre-job Briefing • A crane was staged for use on a DOE site and a manual charger was used to charge the batteries when one of the batteries failed explosively, spreading battery acid 25 feet and injuring three people • The worker performing manual battery charging did not understand the potential problems • The charger's output was set at 24 volts, delivering a constant charging current of approximately 10 amps until it is manually shut off • If not shutoff when the battery is fully charged, a manual charger can overheat and destroy a battery • In contrast, an automatic charger or "Smart" charger will adjust its charge rate dependent upon electrical resistance, and will gradually step down the charging current as the battery charges

  4. Error Reduction Strategies • Pre-job briefing • Questioning attitude • Double verification • Independent verification • Conservative decision making • Flagging (color coding, labeling, procedures, checklists) • Communicating the operating experience to workers • Supervisor / manager monitoring

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