[Hallb-engineering] Fwd: Lesson Learned "Personnel Performing Work in an Electrical Control Panel Without Proper Hazard Mitigation � Idaho National Laboratory"

[Douglas Tilles]

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
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 
taken. 
Discussion of Activities 
Because the panel had been previously evaluated as having "No Exposed 
Electrical Hazards" personnel exposed themselves to unnecessary 
hazards.These include:

�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 
the wire.

�Poor configuration management upon project turnover.

�Personnel incorrectly perceived an urgency to remedy the situation 
immediately. 
Analysis 
Personnel should have performed the following prior to reconfiguring the 
panel.

�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 
performing work.

�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. 
Recommended Actions 
/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 
Facility Management,

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." 
Comments 
6/3/2016 8:02:01 AM by Bailey, Mary Jo 
Submitted to those with SAF603A Electrical Safety Awareness. 
	
Summary 	Lesson ID: 	950 
	Status: 	OK 
	Doc ID: 	2016-JLAB-950 
	Priority: 	Info 
	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 
	Source: 	DOECRD 
	Location: 	INL 
	Cost Savings: 	
	Contact: 	Robert Gomez, SSPSF NFM 866-495-7440 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	5 times Attachments 

    * Control Panel - INL.pdf 

Hazard Issues 

    * Electricity 
    * Other: Work Planning and Communication, 
Skills 

    * SAF603A: ELECTRICAL SAFETY AWARENESS 
Distribution/Notification 

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




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