[Ace] Fw: Employees Receives Shock While Troubleshooting iMac Desktop Computer

[Brad Cumbia]

Notice section for "suspend work".  Anthony will get clarification.

Brad Cumbia

Accelerator Network Engineer
Accelerator SysAdmin Group

Thomas Jefferson National Accelerator Facility
12000 Jefferson Avenue
Newport News, Virginia 23606
Phone (757)269-5839
________________________________
From: JLab ESH&Q <JLab_ESH&Q at jlab.org>
Sent: Wednesday, July 10, 2019 4:29 PM
To: Brad Cumbia
Subject: Employees Receives Shock While Troubleshooting iMac Desktop Computer

Employees Receives Shock While Troubleshooting iMac Desktop Computer
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EVENT: EMPLOYEE RECEIVES A SHOCK WHILE TROUBLESHOOTING IMAC DESKTOP COMPUTER

DATE/TIME OF EVENT:  JULY 8, 2019; 2:15 p.m.
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EVENT DESCRIPTION:

An IT employee was troubleshooting an iMac computer reported to be overheating and powering down. The technician unplugged the machine and discharged the components. The technician then proceeded to remove the front screen to perform a visual inspection of the inside of the machine. There were no visible signs of the machine overheating. The technician plugged in the computer and powered it on to verify that the two fans were operating properly. The technician moved their hand close to the machine's motherboard and power supply in an effort to check for air movement and heat. They inadvertently touched a soldering point within the powered computer. The technician immediately retracted their hand, and felt immediate pain in their ring finger that radiated into their lower forearm and their chest area.

The technician unplugged the machine, and notified the manager and their supervisor about the event. The technician walked to Occupational Medicine for evaluation and was sent off-site for further evaluation. Later that evening the technician was released from the hospital with no restrictions.

EVENT IMPACT:


The Computing and Networking Infrastructure Manager issued a "suspend work" for the group. The "suspend work" stated that no one is permitted to perform work on a computer when an energized case is open or removed without permission from the CNI Manager. If a computer is de-energized and not plugged into a wall outlet or other power source, then the computer’s case may be open or removed and work may be performed on it.

ERROR PRECURSORS/ LESSONS LEARNED:

  *   Risk Perception: When performing troubleshooting work, it is imperative to consider all associated risks, and develop and implement hazard controls before beginning work. This may include the use of specialized tools that will remove the worker from the hazard.
  *   Risk Perception: Any worker that is expected to perform service and maintenance activities on electrical equipment must be adequately trained and qualified before performing those activities.  Even qualified workers must factor-in protective measures to reduce electrical shock hazards when protective covers on equipment are removed and hazardous energy may be present. If mitigation is not possible, then Lock/Tag/Try must be executed if the equipment is to be approached or manipulated.
  *   Risk Perception: It is important that when a person has been shocked or significantly injured that they are escorted to Occupational Medicine for evaluation. This ensures that if something adverse were to happen to them, there is someone there to offer immediate assistance.
  *   Hidden System Response: This system, even though energized, had conductive soldering points that are outward facing which is unique to this brand of machine.
  *   Hidden System Response: Sources of electrical hazards can be found everywhere. This includes electronic equipment in both an office and industrial settings.

WHAT WENT RIGHT?

The employee quickly reported the event to their supervisor and went to Occupational Medicine for evaluation.
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