[Hallb-engineering] Fwd: Lesson Learned "Technician Receives Mild Shock while Troubleshooting a Portable Air Sampler - : Nuclear Waste Partnership, LLC"

[Douglas Tilles]

FYI


----- Forwarded Message -----
From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Tuesday, July 14, 2015 4:00:09 PM
Subject: Lesson Learned "Technician Receives Mild Shock while Troubleshooting a Portable Air Sampler - : Nuclear Waste Partnership, LLC"

Jefferson Lab Lessons Learned : Print Lesson 
	Technician Receives Mild Shock while Troubleshooting a Portable Air Sampler - : Nuclear Waste Partnership, LLC 
	
Statement of Lessons Learned 
For a copy of the original report, see �Attachments� on Lessons Learned page. 

A Radiological Control Technician (RCT) attempted to fix a faulty portable air sampler by removing its fuse and replacing it.  When the sampler continued to fail the RCT attempted to remove the second fuse, but did not disconnect the sampler from the electrical supply, and experienced a mild tingling sensation. 
Discussion of Activities 
On March 4, 2015 a RCT attempted to start a portable air sampler, but the instrument would not turn on.  Based on past experience, but contrary to company practice, the RCT attempted to troubleshoot the instrument by replacing the fuse with one from a known working model. When the sampler again failed to start, the RCT attempted to remove the fuse, neglecting to disconnect the instrument from the electrical supply.  He experiencing a mild tingling sensation and reported to the site nurse for evaluation. 

The RCT had been trained on electrical safety and knew that the correct response for fixing broken equipment was to tag the equipment and generate an �Action Request.� He did not recognize that troubleshooting was not authorized when he attempted to replace the fuse. 
Analysis 
Neither the air sampling procedure nor the manufacturer�s manual effectively communicated the expectations related to troubleshooting the equipment.  

Subsequent investigation discovered obvious scorching, melting and separation from the termination at the instrument switch which would not have been �fixed� by a replacement fuse. 
Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only. 

Immediately after the event, the portable air sampler was tagged out of service.

The following actions were then performed: 

Inspection of the unit, by an electrical subject matter expert and an instrumentation and calibration technician.  It was found that the unit had incurred an electrical fault resulting from less than adequate conductor terminations originally installation by the manufacturer. 

An extent of condition review was performed on all portable air samplers. This review identified five others units that showed evidence of excessive heat buildup and/or arcing. With concurrence from the manufacturer, faulty conductor terminations on multiple units were identified and corrected. 

Periodic preventive maintenance has been scheduled to visually examine the interior electrical components of portable air samplers. 
JLab Preventive Measures 
Jefferson Lab�s Electrical Safety Program specifically states that it is the responsibility of everyone to Request an inspection from a qualified electrical inspector.
�	Be aware of electrical hazards.
�	Perform work using electrical safe work practices.
�	Report electrical hazards to your Supervisor.
�	Submit a Facilities Management Work Request if new, repair, or maintenance electrical work.
�	Report cases of electric shock to Jefferson Lab Occupational Medicine Department.
�	Request an electrical hazard evaluation if a piece of electrical equipment malfunctions. 
Comments 
7/14/2015 3:16:27 PM by Bailey, Mary Jo 
Submitted to those current in :
SAF104: LOCK, TAG, AND TRY
SAF607: HAND TOOLS & LADDER SAFETY
SAF603A: ELECTRICAL SAFETY AWARENESS 
	
Summary 	Lesson ID: 	896 
	Status: 	OK 
	Doc ID: 	2015-JLAB-896 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	7/14/2015 3:12:25 PM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	7/14/2015 3:16:27 PM 
	Source: 	DOECRD 
	Location: 	OTHER 
	Cost Savings: 	
	Contact: 	Brenda Kirkes, Nuclear Waste Partnership, LLC, 575.234.8236 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	2 times Attachments 

    * DOE - Mild Shock.pdf 
Hazard Issues 

    * Electricity 
    * Tools - Machine & Portable 
Skills 

    * SAF104: LOCK, TAG, AND TRY 
    * SAF607: HAND TOOLS & LADDER SAFETY 
    * SAF603A: ELECTRICAL SAFETY AWARENESS 
Distribution/Notification 

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




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