MEMORANDUM. TO: Distribution. FROM: Joe B. Goodson, SA/QA Officer, OTP. DATE: November 18, 1999

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1 MEMORANDUM TO: Distribution FROM: Joe B. Goodson, SA/QA Officer, OTP DATE: November 18, 1999 SUBJECT: Independent Assessment of Beam Physics and Instrumentation The Office of Technical Performance is charged with conducting independent assessments of Jefferson Lab s organizational elements. This Memo forwards the Independent Assessment Report of Beam Physics and Instrumentation which was conducted from September 27 to October 29, 1999, and focused on EH&S activities within this Department s normal operations. The report contains observations, a conclusion, and recommendations. The conclusion must be taken seriously and the recommendations addressed. It is requested that appropriate management attention be directed toward the recommendations and that OTP be provided with the following information by December 20, 1999: the corrective action intended for each recommendation, the estimated time of completion, and the name of the line manager responsible for accomplishing the intended action. The recommendations will be tracked in the SA/QA Data Base and the status reported to the Director s Council at appropriate intervals. Distribution: C. Leemann L. Harwood C. Hovater S. Prior cc: J. Draayer - SURA L. Cardman C. Ficklen H. Loweth - SURA R. Sundelin M. Hunemuller - JSO R. Whitney J. Conley - JSO J. Benesch B. Morgan - JSO M. Wissmann J. Bennett - JSO P. Hunt H. Grunder H. Walter N. Isgur T. Briggs

2 Jefferson Lab REPORT INDEPENDENT ASSESSMENT OF BEAM PHYSICS AND INSTRUMENTATION November 1999 Performed By: Approved By: Hugh D. Williams Assessment Engineer, SA/QA Group Joe B. Goodson SA/QA Officer

3 I. Purpose and Scope of Assessment REPORT INDEPENDENT ASSESSMENT OF BEAM PHYSICS AND INSTRUMENTATION DATES CONDUCTED September 27 - October 29, 1999 The purpose of this assessment is to provide a comprehensive view of EH&S activities within the normal operations of Beam Physics and Instrumentation (BPI). The assessment is intended to complement the Line Self-Assessment which addresses EH&S as an integral part of laboratory work. The scope included: administrative measures; worker awareness; equipment and materials; and personnel protective measures. II. Executive Summary. On the basis of interviews with a broad representation of personnel assigned to BPI and visits to BPI facilities, it appears that safety should be accorded a higher priority by BPI line management. All of the hazards observed are included in the Work Smart Standards set. The existing documentation and practices were found to be appropriate for adequately controlling hazards observed with the exception of those found in Building 59. III. Staff Participation. The following personnel were contacted during this assessment: L. Harwood - BPI Department Manager; C. Hovater - Electronic Instrumentation Development (EID) Group Leader; J. Benesch - Accelerator Design Group; M. Tiefenback - Diagnostics Group; J. Denard - Diagnostics Group; K. Capek - EID Group; M. Crofford - EID Group; M. Wissmann - EID Group (Safety Warden); T. Allison - EID Group (Student); E. Stangland - EID Group (Student); S. Prior - Accelerator EH&S Officer; P. Hunt - Accelerator EH&S; T. Briggs - Plant Engineering; and E. Winslow - Plant Engineering.

4 This assessment report was discussed with L. Harwood, C. Hovater, J. Benesch, T. Briggs, S. Prior, and C. Ficklen. IV. Observations. a. Administrative Measures. Beam Physics and Instrumentation (BPI) is comprised of Accelerator Design and Instrumentation Systems. Instrumentation Systems contains the Electronics Instrumentation Development (EID) and the Diagnostics groups. The Design and Diagnostics personnel are essentially theorists and diagnosticians, working in Accelerator and Physics spaces with the objective of providing analytic, computational, and diagnostic support for design and operational improvements to the CEBAF Accelerator and FEL Facility. The EID Group designs and builds accelerator and FEL instrumentation and controls for installation in Accelerator spaces and the experimental halls. BPI personnel, by virtue of work assignments in different areas, are subject to the work controls in each location. The hall work coordinators and applicable work control documents (SOPs, OSPs, TOSPs, and temporary work permits) ensure that unique hall hazards or conditions are appropriately identified and mitigated for work in the experimental halls. Work in Accelerator spaces such as service buildings, the tunnel, or in Building 59 is considered more routine, i.e., the hazards are adequately addressed in the JLab EH&S MANUAL and, therefore, not subject to additional work control documents. The BPI staff interviewed confirmed their awareness of the Lab s EH&S standards, not only with respect to their personal well-being, but also the protection of their clients through incorporation of requisite safety features in their work products. One member of the BPI staff (J. Benesch) serves as a member of Physics Experiment EH&S Review Committee (E 2 RC). b. Worker awareness. The BPI staff represents a broad span of qualifications, ranging from PhD physicists in the theory and diagnostics fields, through computer scientists, electrical engineers, technical associates, and senior engineering associates, many with years of experience. The most junior technician has more than three years of experience at JLab (EID generally hires students who have worked as EID interns for 3 or more years). Consequently, the technical, hands-on work performed by BPI staff is accomplished by engineers or technicians with significant JLab experience. Design and Diagnostics interviewees confirmed their awareness of the hazards encountered, the associated mitigation measures, and their right to question whether the mitigation measures were adequate. One example cited involved plans to install lead shielding around some new equipment and concerns about lead handling precautions. Patty Hunt was contacted and presented a one hour training program on safety measures for lead handling. As a consequence, the personnel involved were confident the work could be accomplished with minimal risk because of the heightened worker awareness of the hazards and mitigating measures.

5 Many BPI personnel have to work in the experimental halls. The EID staff may spend 20-30% of their time in the halls doing beam diagnostics work. Therefore, the worker awareness provisions associated with the halls are important and include the individual hall hazard training, in addition to the minimum EH&S training required for all JLab workers. Worker awareness is further enhanced by the contents of each hall s bulletin board, including the list of hazards present and associated work control documents prescribing appropriate mitigation measures. Finally, the hall work coordinators ensure workers are trained, familiar with hazards, and aware of the related work control documents. EID interviewees identified a persistent problem affecting work in Room 6 of Building 59 (rainwater leakage at the floor level into an electronics workshop area involving live circuits) and their concern that efforts to seal the leaks had not been successful. The interviewees affirmed their awareness of the hazards inherent in their work, the hazard mitigation measures in the EH&S MANUAL, the opportunity to discuss safety concerns with supervisors and managers, and their right/obligation to stop work if unsafe conditions existed. c. Equipment and materials. The safety-related equipment and materials examined during this assessment were found to be appropriate and well maintained, with the exceptions noted in paragraph d. A review of Accelerator Division EH&S inspection records indicates three discrepancies in Building 59 during the past year. Rainwater leakage to Room 6 was not listed among the discrepancies. d. Personnel protective measures. A review of personnel protective measures within BPI necessarily focuses on the EID Group which performs the hands on work of the Department. EID s work covers instrumentation, controls, feedback, and data acquisition. With this background in mind, personnel protective measures were reviewed in Building 59: Room 6 is a large electronics shop area containing workbenches where work on live equipment components occurs. The equipment being worked on is usually connected to line voltage, but, in general, measures are taken to prevent voltages higher than 20 volts from being exposed. However, the connection to line voltage creates a lowprobability risk of contact with line voltage through operator error, construction error, or component defect. The factors discussed below make the potential consequences of such contact unacceptable. Room 6 has a history of significant rainwater leakage onto its floor, two instances of which have occurred since mid-september, 1999 (On October 1, personnel were observed working on electronics equipment in Room 6, and the carpet in the right rear area of the room was wet); The areas in front of the workbenches were not provided with insulated floor matting, designed to protect personnel working on live equipment (even if the carpet under the mat were wet); Circuits to workbenches in potentially wetted areas were not equipped with Ground Fault Circuit Interrupters (GFCIs); and On two occasions, technicians were observed working alone on energized circuits.

6 The fact that BPI line management was aware of the leakage problem in Room 6 of Building 59 and did not institute timely and thorough protective measures to resolve the problem (work order to Plant Engineering, temporarily relocate work area, etc.) and the application of other applicable safety measures is indicative of complacency with respect to line management s responsibility for safety. Note: following the assessment, but prior to the distribution of this assessment report, GFCI protection was extended to the workbench areas affected by the foundation leakage, and the Room 6 work area was surveyed by a member of JLab s Electrical Safety Subcommittee. e. Attitude (general observations). With the exception of EID workers concerns regarding rainwater leakage into Room 6 of Building 59, BPI staff interviewed during this assessment identified no other work safety concerns. V. Conclusion and Recommendations. a. Conclusion. BPI line managers did not exhibit an appreciation of their responsibility for EH&S in their areas of operation, i.e., to ensure that safe working conditions are provided for the performance of assigned work. b. Recommendations. The following recommendations are made: 1. BPI line management should ensure that the workers in Building 59 are provided a safe work area for work assigned. 2. The electrical safety chapters in the EH&S MANUAL should be amended to include more detail and description of appropriate practical electrical safety measures to enable workers to properly mitigate workplace electrical hazards, in particular work on or near exposed energized sources. 3. Practical aspects of electrical safety training should be provided to all workers routinely exposed to exposed energized sources. VI. Relevant Documentation. The following documents were used during this assessment: Accelerator Design s Line Self-Assessment for period 10/01/96-09/30/97; Jefferson Lab Self-Assessment Program (JLSAP) Directive, Revision 5; Jefferson Lab s EH&S MANUAL; Monthly Building 59 inspection records; and Practical Electrical Safety, D. C. Winburn, Marcel Dekker, Inc., New York