[Hallb-engineering] Fwd: Lesson Learned "Personnel Performing Work in an Electrical Control Panel Without Proper Hazard Mitigation � Idaho National Laboratory"
tilles at jlab.org
Fri Jun 3 10:25:41 EDT 2016
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From: "mbailey" <mbailey at jlab.org>
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Sent: Friday, June 3, 2016 10:00:04 AM
Subject: Lesson Learned "Personnel Performing Work in an Electrical Control Panel Without Proper Hazard Mitigation � Idaho National Laboratory"
Jefferson Lab Lessons Learned : Print Lesson
Personnel Performing Work in an Electrical Control Panel Without Proper Hazard Mitigation � Idaho National Laboratory
Statement of Lessons Learned
Personnel, assigned to verify "as-built" drawing discrepancies noted
during recent work activities in the area, where verifying a
configuration control panel for an exhaust system that was found to have been
upgraded and labeled as having "No Exposed Electrical Hazards."
After removing the cover, a conductor with a frayed end was
discovered.This led back to a 24V relay. At the time, an
Instrumentation & Calibration (I&C) Technician entered the room while on
another job. Personnel discussed the situation with the I&C Technician
and requested the removal of the frayed end and installation of a
wire nut. I&C Technician removed the 24V relay and cut off the frayed
end of the wire, He then re-installed the relay.
Personnel notified their supervisor of the pre-condition and the actions
Discussion of Activities
Because the panel had been previously evaluated as having "No Exposed
Electrical Hazards" personnel exposed themselves to unnecessary
�Failure to stop work when an abnormal conditions was found,
�Failure to notify supervisor prior to taking action.
�Failed to mitigate the potential hazard when removing the frayed end of
�Poor configuration management upon project turnover.
�Personnel incorrectly perceived an urgency to remedy the situation
Personnel should have performed the following prior to reconfiguring the
�Exercise Time Out/Stop Work when conditions are not as expected.
�Ensure management is properly notified *prior* to taking actions.
�Ensure hazards are mitigated prior to proceeding.
�For panels that have previously been evaluated as <50VAC, Trust but
*VERIFY* the voltages are truly <50 volts within the panel prior to
�Enhance communication for work expectations, including when to stop and
notify, questioning attitude, and ensure job expectations are clearly
understood. If the job cannot be performed within the guidelines/tools
set forth by your supervisor, then communicate this with your supervisor.
�Configuration control/drawing acceptance was inadequate for the NORESCO
Energy Systems Performance contract upgrades performed in SSPSF.
�The process for evaluating the operator access to electrical cabinets
should be reviewed to determine if improvements are needed.
/Below are the consequences of the above event.They are provided for
information and discussion purposes only. /
Realizing that this work had been performed outside of the approved work
control for this activity the Supervisor called a time out and notified
Subsequent inspection by Facility Management and the I&C Technician
revealed there was exposed 120VAC inside the cabinet.No voltage was
present at in cut wire.
JLab Preventive Measures
(Jefferson Lab�s Subject Matter Expert has provided the statement below.)
"With any type of work, Jefferson Lab's policy is that when your encounter a change in the original scope, stop and re-evaluate for any new hazards and apply mitigation(s) needed before re-starting the work."
6/3/2016 8:02:01 AM by Bailey, Mary Jo
Submitted to those with SAF603A Electrical Safety Awareness.
Summary Lesson ID: 950
Doc ID: 2016-JLAB-950
Safety Related: NO
Originator: Bailey, Mary Jo
Issued: 6/3/2016 7:55:46 AM
Approved By: Bailey, Mary Jo
Approved On: 6/3/2016 8:02:01 AM
Contact: Robert Gomez, SSPSF NFM 866-495-7440
Queued Emails: 0
Sent Emails: 0
Viewings: 5 times Attachments
* Control Panel - INL.pdf
* Other: Work Planning and Communication,
* SAF603A: ELECTRICAL SAFETY AWARENESS
* *Division Safety Officers (DSOs)
* *Safety Wardens
* *DOE Notification
* *ESH&Q Liaisons
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