[Hallb-engineering] Fwd: Lesson Learned "Electrical Shock of a Non-Electrical Worker - Lawrence Berkeley National Laboratory (LBNL)"

[Douglas Tilles]

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Monday, May 18, 2015 10:00:52 AM
Subject: Lesson Learned "Electrical Shock of a Non-Electrical Worker - Lawrence Berkeley National Laboratory (LBNL)"

Jefferson Lab Lessons Learned : Print Lesson 
	Electrical Shock of a Non-Electrical Worker - Lawrence Berkeley National Laboratory (LBNL) 
	
Statement of Lessons Learned 
For a copy of the original report, see �Attachments� on Lessons Learned page. 

A worker received a 120 VAC shock while assisting an electronics technician to troubleshoot cooling water flow switches. 
Discussion of Activities 
After completion of a summer maintenance shutdown, a cooling water valve had not been properly restored to its normal �open� position.  Thus, when workers prepared to start the bending magnet's 480 VAC power supply, the interlock chain in the Control Room indicated a cooling water flow problem. The on-duty electronics technician was dispatched to troubleshoot the flow switches.  He locked out and tagged out (LOTO) the electrical circuit, unplugged one of the flow switch connectors, inserted a jumper, and energized the circuit. The jumper was custom built with proper pins and was insulated except for two locations which presented exposed metal.  However, the cooling water flow path pipes was not labeled, so the electronics technician requested assistance.  One of the workers arrived to help identify the water flow path. 

The worker was not aware of any electrical hazard as no job briefing was performed and no barriers were in place to mitigate or identify the hazard.  The worker climbed a fiberglass stepladder and, when pointing to the water pipes, contacted a grounded pipe with his right hand while brushing against the exposed metal on the energized jumper with his left elbow, thus receiving a shock. 

Work stopped immediately.  The worker reported to his supervisor and was sent to Health Services for evaluation. He was released with no injury. 
Analysis 
This incident highlights the following deficiencies:

Labeling of pipes, valves, flow switches, and flow paths had not been completed due to insufficient resources.  Labeling work, started in late 2013, was stopped in late spring of 2014 when the individual assigned to the project left the Laboratory. At the time of the incident, the labeling project was on hold until additional resources became available. 

Laboratory's enforcement of the policy to perform work de-energized needs improvement.   Based on staff interviews, doing work de-energized was not required.  This troubleshooting task could have been performed de-energized.

The principles of Integrated Safety Management (ISM) were not applied.  The scope of work was not well defined and the hazards were not entirely analyzed so the controls were inadequate. Without conducting a thorough hazard analysis, including developing and implementing proper controls, work was performed in a manner that led to the electrical shock. 
Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only. 

Several corrective actions were developed to mitigate recurring issues: 

�	Complete the labeling of the Building's mechanical and electrical systems; 
�	develop and implement an electrical safety checklist for all energized and de-energized work 
�	Write and implement a general troubleshooting procedure, to be used by all Building operations, electrical and mechanical personnel. 
JLab Preventive Measures 
ES&H Manual Chapter 6200 Electrical Safety Program provides guidance and requirements for implementing safe electrical work practices and maintaining an electrically safe workplace. It describes the minimum requirements for a qualifying electrical safety inspection, electrical personal protective equipment, general electrical safety, and electrical hazard labeling used at Jefferson Lab, the electrical code equivalency procedure, and the electrical authority having jurisdiction process. 
Comments 
5/18/2015 9:06:27 AM by Bailey, Mary Jo 
Submitted to those with:
SAF104: LOCK, TAG, AND TRY
SAF117: EH&S MANAGEMENT TRAINING
SAF603: SAF603A FPA-70E BASIC ELECTRICAL TRAINING 
	
Summary 	Lesson ID: 	887 
	Status: 	OK 
	Doc ID: 	2015-JLAB-887 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	5/18/2015 8:47:49 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	5/18/2015 9:06:27 AM 
	Source: 	DOECRD 
	Location: 	LBL 
	Cost Savings: 	
	Contact: 	Theresa Triplett / 510-486-7401 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	3 times Attachments 

Hazard Issues 

    * Electricity 
    * Other: Work Planning and Communication, 
Skills 

    * SAF104: LOCK, TAG, AND TRY 
    * SAF117: EH&S MANAGEMENT TRAINING 
    * SAF603: SAF603A FPA-70E BASIC ELECTRICAL TRAINING 
Distribution/Notification 

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




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