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Table B-1. Organization of Examples
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Volume 2 of 2
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Example 2: Utilizing a Multi-disciplined Team during Job Planning


DOE-STD-1120-2005/Vol. 2
EXAMPLES OF APPLYING DOE-STD-1120 CONCEPTS
WORK PLANNING/HAZARD IDENTIFICATION
Example 1:
Integration of Worker Hazard Considerations into Work Planning
As part of the task to remove useable process equipment during a facility decommissioning, a welder was
using a cutting torch to cut out large cylindrical sections. The work was similar in many ways to work
performed in another building at the site during the past year, as well as to extensive equipment
replacement activities necessary to support operations in the past. Because of these similarities, the
operating contractor classified the work as routine maintenance, thereby eliminating the requirement for a
task-specific work plan.
During the cutting operation, a spark or piece of hot metal ignited the welder's coveralls below the left
knee. The welder was wearing multiple layers of clothing, radiological protective equipment, and a
welder's mask that severely limited his ability to detect and extinguish the flames. Since the welder was
working alone, the flames spread undetected until they were beyond his ability to extinguish them without
assistance. By the time a co-worker responded to the emergency, the flames had totally engulfed the
welder's body. He received third-degree burns on more than 95 percent of his body and died the
following day.
The Type A Accident Investigation Board Report notes several deficiencies that contributed to the
fatality--failure to identify a fire watch with appropriate personnel safety responsibilities and training;
failure to plan the work adequately; failure to react to numerous clothing fires during welding prior to the
accident because of a failure to foster an atmosphere that encouraged reporting of incidents; use of
protective equipment that exacerbated the fire hazard; disregard of a formal lessons-learned report from
an identical activity the prior year; inadequate provisions for emergency egress; and failure to notify the
Industrial Hygiene (IH) Department for surveying the working conditions/controls as required by the
work permit. None of these activities required the elaborate or extensive analysis usually associated with
a SAR--just adherence to normal industrial safety practices, plant procedures, and the presence of an
effective safety culture emphasized by management.
B-4


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