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2010 to Present Lessons Learned

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2009 & Prior Lessons Learned

Chemical

19970725 Mixing and Storing Incompatible Chemicals

19981021 Lessons learned from Recent Copper Welding Compliant

19981223 Kitchen Fire - Lesson Learned

20020218 Los Alamos National Laboratory Beryllium Transfer

20080408 NWA Corrosive Liquid Spill

Compressed Gasses

19980714 Compressed Gas System Filter at Savannah River

19981007.01 Meson Assembly Building (Weld Shop) Compressed Gas Cylinder Incident

19990519 Hydrogen Fluoride Cylinder Ruptures at University Laboratory 5/19/99

19990728 Transport Of Compressed Flammable Gas In University Vehicle

20031104 Acetylene Mishap

Construction

20050711 Fiber Optic Cable Cut During Excavation

Cryogens/Vacuum

19960322 LN2 Dewar Incident at CDF

19970124 Liquid Nitrogen Dewar Vessel Cracks

19981007.02 The GEnTarget Accident at Jefferson Lab and Lessons Learned

19990331 Harzard Identification Prevents Injury from Pressurized Empty 55 Gallon Open-Top Drum

19990429.02 Unauthorized Modification Results in Nitrogen Release

20000630 Employee Pinch Injury While Moving Dewar

20071015 Circle Seal Relief Valve Failure

Electrical

19960726 Ground Fault In An Overhead Hoist 480

19961220 Dump Trucks Contact Overhead Lines

19970311.01Underground Utilities Detection and Excavation

19970402 Forklift and Overhead Power Line, Near Miss Incident

19970830 Electrical and Lockout/Tagout Work Process Review

19971216 Wrong Motor Control Center Locked Out/Tagged Out

19980318 Electrical Flashover Accident at Fermilab

19980923 Electrical Near Miss Demonstrates the Importance of Proper Planning and Communication

19981117 Abandoned Cable in Cable Tray Causes Shock to Employee

19990828 Cut Electrical Conduits

19991231 Electrical Short in Heat Tape

20000921 Crane Comes Too Close to 13.8 kVA Overhead Power Line

20040310 Electrical Mishap at Fermilab SiDet Facility

20060503 Improper Discharge of a Battery Results in Explosion

20060922 Following Procedures Avoids Injury

20061030 Plug Fault

20070201 Incorrect Grounding of Welding Machine Leads to Shock

20070807 Extremely High Humidity Caused Transformer Arc Flash

20080822 Altered Equipment Set-up and Inadequate Training Leads to Mild Shock

Environmental

20040831 - CHL Oil Spill

20060216 - Corrosive Waste Mis-characterization

20070307 - Sharp Objects in Waste Disposal Bag

Fall Hazards

19961105 Defective Full-Body Harnesses Recalled

19980127 Lab F - Near Miss/Potential Fall

19981023 Failure to Mark Open Floor Tile Results in Injury

20021029 Slip on Stairs Teaches Several Lessons, October 2002

20090415 Easy Fix Trip Hazard for Airline Hose

Flammable/Fire Hazards

19960816 Gasoline Cans Explode And Burn

19961016 Failed Battery Backup Systems Become Potential Ignition Sources

19970324 Fatality at Oak Ridge

20020805 Materials Development Lab Aluminum Fire, August 5, 2002

20031021 Flammable Shredder Lubricant Spray Flashed While Running Paper in the Shredder

20061031 Improper Storage of Gasoline Generator

20080405 Process Improvement - Main Ring Prescribed Burn FMA2

20080620 Kitchen Fire

20090512 Wilson Hall False Fire Alarm

Hoisting/Rigging

19960104 Crane & Forklift Safety

19960505 Bridge Crane Hoist-Shock Incident

19960606 Lift Truck Hand Brake

19971030 Lab F - Rigging Incident Injures Contract Employee

19980504 Lab 4, Village Machine Shop Crane Incident

19980717 Employee Injured During Hoisting and Rigging Activities

20010223 Wedged Forklift Tine Causes Injury 2/23/2001

20010313 Hoisting and Rigging Failure 3/2001

20010829 Lifting Sling Fails Because Of Inadequate Chafing Protection

20011031 Iron Pipe Falls From Trailer Bed

20011106 Near Miss Accident Involving Stacked Recycling Bins

20020117 Steel Block Dropped From Electromagnet 01/17/2002

20020204 Equipment Damage Due to Failure to Secure Transport Cargo: 2/4/02

20030530 Failure of Support System During Cutting of Steel

20040804 Overkill Not Always Better When Rigging

20061011 Load Tips from Lift Truck

20070424 Rhino Horn Lifting Failure Near Miss

20070521 Powered Industrial Truck Injury

20070611 Matrial Move Near Miss

Other

19961002 Four Die In Non-DOE Confined Space

19970311.02 Lockout/Tagout Programs

19970328 Cost Avoidance And Improved Product Through Process Changes

19970828 Use of Back Belts by Fermilab Employees

19971015 Lessons Learned in Occurrence Reporting

19971202 Construction Fatality at BNL

19980418 Microbiologically Influenced Corrosion in the Main Injector Low Conductivity Water System

19980930 Failure to Ensure Vehicle in Gear Causes Injury

19981215 DOE Field Visit to Argonne National Laboratory - East (ANL-E) Lessons Learned

19990302 Slips on Ice - Reminder

19990726 Near Miss Involving Hurricane Fan

19991013 "I Can't Believe That I Did That!"

19991117 Failed Parker Valve

20001020 Who's Dr. Foxen

20010521 120 GeV Switchyard Beamline Magnet Dropped

20020405 Think About It!

20020731 Forklift Pins Employee Between Steel Shielding Blocks July 2002

20030422 MC 7 West Overhead Door Failure

20030503 Back Pain Results From Moving Welding Machine

20031111 Hydrogen Sulfide Generation at MI-12

20050106 Choose Correct Deburring for the Job

20050915 Coil Shim Stock Injury

20060814 UV Photokeratitis

20061108 Incorrect Tool Choice

20070117 Manhole Cover Causes Lacerations to Three Fingers

20070411 In-House Design Cutting Tool Contributes to Employee Injury

20070619 Inexperience With Drill Press Leads To Laceration

20080521 Inattention when using Exacto Knife Results in Laceration

20080619 Poor Work Practice Results in Injury

20090406 CDF 4-Wheel Dolly Incident

20091001 Unclear Roles and Responsibilities Leads to Poor Communication

Radiation

19970129 Radiation Safety System

19970408 Radioactive Scrap Discovered in Lab 4 Metal Scrap

19980209 Tritiated Vacuum Pumps

19980625 Accelerator Access Control Problems

19990429.01 Resolving Conflicts Between Radiological and Industrial Safety Requirements

19990603 Accelerator Radiation Safety Problems are Considered to be Regulatory Violations

19990806 Screening Scrap Metal for Radioactivity

20000101Unusually High Dosimetry Badge Result

20000508 Improper Material Move Radiation Survey

20020207 CDF Calorimeter Module Relocation 2/07/2002

20060721 Controlled Acess Procedure Violation at Meson Test Beam Facility

20070911 Contamination Event at the Low-Level Radiation Facility (Site 40)

20081104 Unauthorized Use of Radioactive Water Source

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