[Hallb-engineering] Fwd: Lesson Learned "Implement a Conservative Approach when Working with Multi-wire Branch Circuits and Other Neutral Hazards- Mission Support Alliance, Hanford Site"

[Douglas Tilles]

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Subject: Lesson Learned "Implement a Conservative Approach when Working with Multi-wire Branch  Circuits and Other Neutral Hazards- Mission Support Alliance, Hanford Site"

Jefferson Lab Lessons Learned : Print Lesson 
	Implement a Conservative Approach when Working with Multi-wire Branch Circuits and Other Neutral Hazards- Mission Support Alliance, Hanford Site 
	
Statement of Lessons Learned 
Electrical workers at DOE facilities must be trained to a more 
conservative approach than the commercial sector when working with 
potential shared neutrals. Actions must be institutionalized to prevent 
repeat events. A briefing or one-time training is only a temporary fix 
and a set-up for repeating the same event in the future. 
Discussion of Activities 
While removing an old GFCI outlet, an electrician discovered two neutral 
wires under one line terminal screw. When the electrician removed the 
wires from the screw he noticed a spark as the wires were separated. 
Separating the wires disrupted the continuity of the neutral circuit 
causing one of the neutral wires to become energized. Work was 
immediately stopped and the outlet was returned to a safe configuration. 
The electrician�s actions were consistent with general industry work 
practices. 
Analysis 
The electrician did not recognize the potential for a neutral hazard. 
The panel schedule did not indicate a multi-wire branch circuit. The 
configuration of the wiring, with only two pairs of wires, did not 
indicate a multi-wire branch circuit. The electrician, therefore, did 
not treat the neutral as a potential neutral hazard. Due to the nature 
of shared neutrals there was no voltage to detect until the continuity 
of the neutral was disrupted. 
Recommended Actions 
Below are the consequences of the above event.They are provided for 
information and discussion purposes only.

The electricians performed circuit verification and documented the 
results in the work package.

Future actions to be taken:

 1. Institutionalize training on shared neutrals in site electrical
    training courses for electricians, instrument technicians and
    controlling organization administrators.
 2. Include text, in the Job Hazard Analysis Electrical Safety
    Checklist, that a neutral wire may go hot when cut, voltage rated
    PPE should be worn when cutting a neutral wire, and that a zero
    energy check should be made before and after the wire is cut.
 3. Attach Warning labels to electrical panels that are known to have
    multi-wire branch circuits. 
JLab Preventive Measures 
(Jefferson Lab�s Subject Matter Expert has read and approved this lesson.)

In accordance with ES&H Manual Chapter 6200 Jefferson Lab�s Electrical 
Safety Program, only qualified electrical workers are authorized to work 
on energized equipment, and only to a limited mode and class.Only 
licensed electrical tradesman are authorized to work building�s 
electrical wiring. 
Comments 
1/21/2016 11:22:20 AM by Bailey, Mary Jo 
Submitted to those with SAF104: LOCK, TAG, AND TRY and
SAF603A: ELECTRICAL SAFETY AWARENESS training 
	
Summary 	Lesson ID: 	930 
	Status: 	OK 
	Doc ID: 	2016-JLAB-930 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	1/21/2016 11:18:35 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	1/21/2016 11:22:20 AM 
	Source: 	DOECRD 
	Location: 	OTHER 
	Cost Savings: 	
	Contact: 	Gerald Whitney 509-372-2166 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

    * DOE - GFCI Outlet.pdf 

Hazard Issues 

    * Electricity 
    * Lock, Tag, Try 
Skills 

    * SAF104: LOCK, TAG, AND TRY 
    * SAF603A: ELECTRICAL SAFETY AWARENESS 
Distribution/Notification 

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




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