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An Evaluation of Recent Events Involving Hazardous Energy at INL Facilities

Idaho National Laboratory (INL) Facilities and Site Services (F&SS) has experienced 14 reportable events relating to work performed under lockout / tagout (LOTO) during the period of March 4, 2019 through August 18, 2020. The 14 events are described in Appendix A and were numerous enough and similar enough in nature to be indicative of an adverse trend that warranted further evaluation. A qualified cause analyst was assigned to lead a team in the review of these non-compliances, to determine commonalities, and to provide recommendations to the sponsoring organization. The team focused on both individual and institutional behaviors as well as the LOTO process and procedure. The non-compliances were reported in the Department of Energy (DOE) Occurrence Reporting and Processing System (ORPS) and/or the INL issues tracking system.

99 GENERAL AND MISCELLANEOUS↗

LOTO Training Flow Simulator Design

The LOTO Training Flow Simulator Design poster discusses the intended purpose of the simulator along with the steps taken in the design process. It highlights the two main systems designed in the primary flow loop and the bubbler system, along with a brief description of the flow calculations made to ensure the functionality of the system.

42 - ENGINEERING↗

Dynamic Instructions for Lock-out Tag-out

Lock-out tag-out (LOTO) instructions protect personnel from unex-pected re-energization or start-up of equipment that is under maintenance. Even though there is rigorous training associated with LOTO activities, incidents still occur. Idaho National Laboratory is researching and developing dynamic LOTO instructions, which supports automatic place keeping, personnel working on mul-tiple instructions, and multiple work groups completing the same instructions. Researchers identified user needs through subject matter expert interviews, ob-servations, and classroom training. Failing to identify potential hazards during LOTO can cause injury or death to personnel. Dynamic instructions help to guide the user seamlessly through the instructions. Combining planning and record keeping may lead to clearer, more applicable instructions which addresses the reason for compliance issues with current paper-based procedures.

99 - GENERAL AND MISCELLANEOUS↗