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U.S. LHC Safety Stand Down. October 24, 2006 Attended by ALICE, ATLAS, CMS, LARP, and LHCb members from the U.S. This is an open meeting. We informed Aymar and Engelen who consider it a “private meeting” – no intent to criticize CERN’s excellent safety record.

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U s lhc safety stand down l.jpg
U.S. LHC Safety Stand Down

October 24, 2006

Attended by ALICE, ATLAS, CMS, LARP, and LHCb members from the U.S.

This is an open meeting. We informed Aymar and Engelen who consider it a “private meeting” – no intent to criticize CERN’s excellent safety record.

The meeting is being attended by the ATLAS and CMS GLIMOS (Group Leader in Matters of Safety) Olga Beltramello and Christoph Schäfer, the ATLAS Technical Coordinator, Marzio Nessi, the heads of safety at BNL and Fermilab, Jim Tarpinian and Bill Griffing, and DOE/NSF here for the RRB.

Motivated by the recent incident in ATLAS

Outline l.jpg

  • The events that led to the incident

  • The likely recommendations to come from the CERN investigation (some changes have already been implemented by ATLAS)

  • Input from U.S. personnel working at CERN for suggestions on how to improve safety

    • We will go in turn: ATLAS, CMS, ALICE, LHCb, LARP

    • We do not want this to be a gripe session – but observations or questions which should be addressed or followed up

  • Action items

  • Conclusion

Slide6 l.jpg

From Marzio Nessi’s report at RRB

  • -Manipulation procedure :

  • - procedural error : one pillar of the table was unbolted from the floor after installation. The information was not logged correctly. When the table was lifted, this beam fell on the floor inside the trench.

  • Safety perimeter :

  • - the crane operators have correctly delimited the entrance to the zone (trench A), but some of the ATLAS users have violated the safety perimeter (before the manipulation started). One person entered in the zone just a few minutes before it was finally evacuated.

  • Zone evacuation and inspection

  • - Just before starting the lifting operation, the zone was visually inspected and kept under visual inspection. Nobody was allowed to enter the zone at any moment during the operation.

  • Reporting and immediate actions

  • - CERN safety coordinator called in, investigation started:

  • Inquiry report after incident nr. 71

  • - Zone secured, operation completed, access inside rerouted

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  • Oct. 12, 2006 ~12:15 Incident occurred and ATLAS GLIMOS and CERN safety notified

  • Oct. 12, 2006 evening RAL orders all staff to stay out of the pit

  • Oct. 14, 2006 Peter Jenni and Marzio Nessi notified Richard Nickerson, UK National Contact Physicist about the incident and assured him that

    • A new access routes to sector 13 calorimeter area would be marked and be safe and operational

    • Secondary escape route would be marked and safe and operational

    • Installation and commissioning work has restarted

  • Oct. 16, 2006 U.S. learns about the incident via email to DOE!!!

  • Oct. 16, 2006 Mail sent to all U.S. ATLAS staff to be aware of rigging

  • Oct. 16, 2006 Full hearing about the incident by CERN safety with all witnesses

  • Oct. 17, 2006 Meeting at BNL with Office of Science heads of safety:

    • Recommended Prudent Avoidance – message sent out

  • Oct. 18, 2006 Access changes to Sector 13 announced to ATLAS System Leaders

  • Oct. 19, 2006 Incident discussed in ATLAS Technical Management Board

  • Oct. 20, 2006 Incident discussed in ATLAS Executive Board

  • Oct. 23, 2006 Incident discussed with DG by U.S. reps to RRB

    • DG tells us that we will receive the report of the incident

  • Oct. 23, 2006 U.S. LHC Safety Stand Down announced

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Change in Access to Sector 13

Date: Wed, 18 Oct 2006 07:29:25 +0200

From: Olga Beltramello <Olga.Beltramello@cern.ch>

To: George Mikenberg <Giora.Mikenberg@cern.ch>, Bob Stanek <Robert.Stanek@cern.ch>, Leonardo Rossi <leonardo.rossi@ge.infn.it>, Horst Oberlack <horst.oberlack@cern.ch>Cc: Peter Jenni <Peter.Jenni@cern.ch>, Marzio Nessi <Marzio.Nessi@cern.ch>,

Olga Beltramello <Olga.Beltramello@cern.ch>

Subject: TR : Sector 13 Atlas

Dear Colleagues,

After the facts of last Thursday, we have decided to reorganize the access to the sector 13, avoiding from now on to cross the trenches.

All this was done last Friday and the CERN safety coordinators inspection took place yesterday. After few iterations and after having restored the 2 emergency exits (towards sector 1) we have received a positive answer. The last request of John is being implemented and will be ok this morning.

So from our side there are no formal reasons to prevent people to transit via this new route to the inside of the detector and to work on the barrel calorimeter front face. A new signalization has also be put in place.

If you have any doubt on this, please contact us.

best regards,

Olga Beltramello (ATLAS GLIMOS)

Marzio Nessi (ATLAS TC)_______________________________

De: John Robert Etheridge

Date: mar. 17.10.2006 16:36

À: Olga Beltramello

Cc: Francois Butin; Marzio Nessi; Herve Buret; Marc Vadon Objet : Sector 13 Atlas

Dear Olga,

Further to our visit yesterday, the Atlas meeting this morning and our subsequent visit, we note that all the modification have been carried out, except for the rails placed under the scaffolding base plats to distribute the load, once this has been done then the sector can be reopened.

We would like to bring once again your attention to the limited space for your evacuation routes; we would ask that Atlas take there responsibility for this situation and make sure that regular visits are carried out with the fire service to ensure they are aware of the situation as the work progresses.

Copy register journal.

Yours faithfully

John Etheridge

On behalf of the safety coordination

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Likely Recommendations

  • Any modification to a piece of apparatus or tooling must be documented

  • Although this case worked, riggers should be reminded that more than one person must patrol such a complex area

  • Restricted areas must be marked better and with time information and everyone will rigorously obey such signage

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CERN Safety Organization is Evolving

  • The DG has an article in the latest Bulletin

  • More responsibility will be given to the Departments and Divisions

  • The details will only be known ~ Jan. 1, 2007

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Issues which need to evolve at CERN

  • Training

    • Determine who has responsibility for determining which advanced courses a person must take

      • For example: fall protection, electrical safety, magnetic fields, scissors lift

    • Communicate this to the Team Leaders so they can follow up and make sure the training is taken

    • Pepin Carolan has a CERN/U.S. task force working on this

  • (Where is the ATLAS daily work planning posted? Lights going out at xx:yy etc)

  • Incident reporting

    • Develop a system where those that need to know the facts get notified

      • What is the SOP – standard operating procedure? Who gets notified?

      • Suggest at least the National Contact Physicists should be added to Project Leaders

      • Currently the head of PH is notified if there is an accident

    • Reports should not include proper names and should be released more widely

    • Lessons learned should be released very widely

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Input from you

  • What additional things should we discuss


  • CMS

  • LHCb


  • LARP

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Action Items

  • Continue with the development of the CERN/U.S. Taskforce on Safety Training

  • Convince CERN to become more open about the communication and reporting of incidents  and of lessons learned from them

  • Keep work packages updated to make sure that all workers are listed and that their supervisors perform their jobs properly

  • Review the list of individuals who receive information about all aspects of safety, and consider a wider distribution list

  • Develop training courses that are more experiment (e.g., ATLAS or CMS, etc) specific, pointing to individual local hazards

  • Make certain that safety training for U.S. personnel includes discussion of the differences in safety cultures at U.S. laboratories and at CERN, as a vehicle for enhancing the understanding of safety practices at CERN

  • Define “Stop Work” as a universal phrase for potentially dangerous activities that can be adopted and used by personnel from all nations working on the CERN site

  • Always inform those responsible for safety of any questions or observations that relate to safety at the working place

  • CMS should follow ATLAS in improving its marking of restricted areas in terms explicit dates and times of the start of rigging operations, and removing such postings promptly when the operations are completed

  • Use throughout the better markings available at USA15

  • Consider developing a more comprehensive mailing list for U.S. personnel for announcing and informing those on the CERN site about current safety issues

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  • Thank you for attending

  • Many of you are very challenged in your daily work and face many risks

  • You can reduce these risks if you are able to be a bit detached in your processing so in the foreground

    • Safety is always your first concern

  • Please take this opportunity to realize that “we” place your safety as our highest concern