[Hallb-engineering] Fwd: Lesson Learned "Electrical Incident X-705 - Fluor-B&W"

Dave Kashy kashy at jlab.org
Mon Aug 26 20:42:45 EDT 2013

----- Forwarded Message -----
From: mbailey at jlab.org
To: mbailey at jlab.org
Cc: robertl at jlab.org
Sent: Monday, August 26, 2013 4:00:44 PM
Subject: Lesson Learned "Electrical Incident X-705 - Fluor-B&W"

	Electrical Incident X-705 - Fluor-B&W 	
Statement of Lessons Learned 
For a copy of the original report, see Attachments on Lessons Learned page

A recent voltage meter failure highlights issues with training and work package preparation and demonstrates a need to understand the importance of personal protective equipment (PPE) requirements and the need for accuracy in the development of work packages. Discussion of Activity 
On Tuesday March 12, 2013 electricians were tasked with troubleshooting a malfunctioning hand table heater.  The work was took place inside a Contamination Area (CA) and the workers were dressed in the PPE required for the CA.  During the work evolution an electrician was attempting to check the voltage at the switch when a flash was generated when the probes were placed on the switch. Analysis 
1.	The work package was not complete and had conflicting information:
a.	The work package should have been for troubleshooting a hand table heater, but Emergency Egress lighting maintenance was referenced in the work instructions.
b.	There was no indication of the type of LOTO - single source or permitted.
c.	Many inaccuracies appeared to be the result of "cut and paste" errors.
d.	The Radiological Work Permit was marked N/A, yet the work was performed in a transuranic contamination boundary.
e.	Safety Task Assignment requirement was not marked.
f.	Proper signatures were not documented on work package.

2.	The JHA had work activities and hazards addressed that were not part of the scope and did not adequately cover the hazards associated with the work.

3.	PPE requirements were not clear to the workers either from prior training or the JHA/Pre job brief.

4.	The Post Job Brief was not in the submitted work package.

5.	NFPA 70E PPE calculation tables were used in place of the ARC flash analysis.

6.	Multimeter was not subjected to Operational verification protocol prior to and after use.

7.	The Lock Out / Tag Out procedure was violated when multiple locks were removed by one worker. 

8.	Electricians were wearing the appropriate Radiological PPE but not the appropriate Electrical PPE. Recommended Action 
None for Jefferson Lab at this time.

Training was provided highlighting the importance of accuracy in work packages.

A job hazard analysis (JHA) preparation briefing was developed by the JHA/Safety groups to offer guidance to the preparers in the creation and approval of JHAs. 

A briefing was held with the package preparers explaining that PPE is to be clearly identified and addressed in the JHA, Work package, STA/ Pre Job brief/ Post Job Briefing, etc. 

Crew members involved in the incident were retrained on the LOTO system. 

A briefing was created to provide the guidelines for SIV in accordance with NFPA70E.

A memo was issued requiring an Arc Flash Hazard Analysis for work involving energized panels over 120 volts. 

An Electrical Safety Committee was created to review electrical projects and program. 
8/26/2013 3:09:13 PM by Bailey, Mary Jo 
Submitted to those with current �SAF603A: ELECTRICAL SAFETY AWARENESS Training 	
Summary 	Lesson ID: 	742 
	Status: 	OK 
	Doc ID: 	2013-JLAB-742 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	8/26/2013 3:08:09 PM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	8/26/2013 3:09:13 PM 
	Source: 	DOECRD 
	Location: 	OTHER 
	Cost Savings: 	
	Contact: 	Rich Rhoads, Safety, 740/897-2483 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	3 times Attachments 

    * DOE Lessons Learned - Electrical4.pdf 
Hazard Issues 

    * Electricity 


    * *Division Safety Officers (DSOs) 
    * *Safety Wardens 
    * *DOE Notification 
    * *ESH&Q Liaisons 

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