1. Type B Report - Draft Facts for Startle Hazard Event Collider-Accelerator Department 12-01-2009 Take 5 for Safety

2. Startle Hazard – Poor Work Planning Contributed (Type B Draft) No Scope of Work Work Order was generic: “move man-lifts;” no locations listed No Hazards Identification The work order did not list any hazards in the job description There were no modifications made to that work order to address hazards associated with 1005H once it was discovered the man lift was at that location No Hazard Controls Implemented In this accident, identification of the noise/startle hazard was deficient, so controls were never put into place However, there were two paths that led to this particular accident, one being the unidentified hazard path and the other being the path that brought the worker into contact with the hazard No Feedback and Continuous Improvement In July 2009, a sub-contractor working through F&O was painting the exterior of Building 1005H The automatic relief vent had been triggered at the end of the compressor run and it had startled the sub-contractor and he reported this to the F&O painting supervisor The F&O supervisor verbally communicated the incident to someone in the cryogenics group and it was confirmed that it was the expected operation of the compressor No further actions were taken and the feedback was not recorded on the work permit for the painting job 2

3. Startle Hazard – Unidentified Pulsed Noise Hazard Contributed (Type B Draft)  High dBA pulsed noise from reliefs not identified as a hazard:  1981: Building 1005H was constructed as part of ISABELLE project  1983: Safety Analysis Review conducted for the ISABELLE project was for all facilities including Building 1005H  1983: ISABELLE project was curtailed, and the Building 1005H was operated in a maintenance mode  1991: The Relativistic Heavy Ion Collider (RHIC) project began and, subsequently, start-up operations for Building 1005H were evaluated  1999: A Safety Analysis Document (SAD) and Accelerator Readiness Review were performed for RHIC, which included a review of 1005H  2004 – 2009: Facility Risk Assessments and Job Risk Assessments were performed for 1005H and work at 1005H as part of the OHSAS 18001 Standard  Noise surveys were performed at various times throughout 1005H history, both inside and outside, and they focused on continuous noise levels 3

4. Type B Report – Sections To Be Completed  Events and Causal Analysis  Conclusions  Judgments of Need 4

5. C-AD Actions  Review work order systems and work planning practices involving non-C-AD workers at C-AD and ensure they meet the requirements of OPM 2.28 for work planning  Meet with individual C-AD Groups and hold a critique session with each Group to learn about specific problems, drawbacks or glitches with the Group’s work environment, equipment, schedule, planning systems and/or procedures 5