[Hallb-engineering] Fwd: Lesson Learned "Employee Receives Electrical Burn while Plugging in a Floor Lamp - Argonne National Laboratory"

[Douglas Tilles]

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Monday, June 6, 2016 10:00:11 AM
Subject: Lesson Learned "Employee Receives Electrical Burn while Plugging in a Floor Lamp - Argonne National Laboratory"

Jefferson Lab Lessons Learned : Print Lesson 
	Employee Receives Electrical Burn while Plugging in a Floor Lamp - Argonne National Laboratory 
	
Statement of Lessons Learned 
Compromised cord insulation, corroded conductors, and a wall switch in the "on" position cause first degree electrical burns to an employee's right thumb and index finger. 
Discussion of Activities 
On February 15, 2016, an employee entered a guest room and attempted to turn on a floor lamp with the wall switch.  When nothing happened he walked over to investigate, as the lamp was typically plugged into a wall receptacle which was energized by the switch.  Moving a nightstand he found that the lamp had indeed been disconnected from the wall.  There was no observable damage to the lamp, cord, plug, or receptacle, so he attempted to plug it back into the wall.  Upon contact with the receptacle, the plug flashed inside his hand causing first degree electrical burns to the thumb and index finger, and covering the palm in soot.

 

The employee reported the event to the supervisor who called 911.  After being examined at the emergency room and receiving first aid only treatment, the employee returned to work with no restrictions. 
Analysis 
Positioning of furniture, in this case the nightstand, up against a rear exiting power cord, with no strain relief, adversely affected the integrity of the cord, crimping the conductors and causing damaging to the insulation over time.   

Electrical components degrade over time. Floor lamps, over 20 years old, would be within their end-of-life failure period.  However, employees habitually replugged the lamps into the wall with the switch in the "on" position even when  it resulted in the lamps flickering or not turning on at all. 
Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only.

1)      Purchase and install new floor lamps for all rooms. Lamps to have polarized plugs that are designed with the power cord coming out from the side to ensure proper strain relief and prevent crimping.

2)      Develop a formal Lessons Learned report and present to housekeeping and maintenance employees.

3)      Inspect all facilities for evidence of furniture compromising the integrity of power cords. 
JLab Preventive Measures 
(Jefferson Lab's Subject Matter Expert has read and approved this lesson.)

Janitorial staff do not plug or unplug any electrical equipment (e.g. light fixtures, coffee pots) into any office or area outlet.  Cleaning crews only utilize electrical outlets for their industrial cleaning equipment (e.g. such as a backpack vacuums; floor cleaning equipment; blowers; etc.)  Janitorial staff are trained on the safe handling industrial equipment.  Training includes ensuring equipment is in the off position prior to plugging the electrical cord into an outlet. 
Comments 
6/6/2016 8:42:56 AM by Bailey, Mary Jo 
Submitted to those current in SAF120kd Safety Observation Program 
	
Summary 	Lesson ID: 	951 
	Status: 	OK 
	Doc ID: 	2016-JLAB-951 
	Priority: 	Best Practice 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	6/6/2016 8:27:04 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	6/6/2016 8:42:56 AM 
	Source: 	DOECRD 
	Location: 	ANL 
	Cost Savings: 	
	Contact: 	Jeff Alicz, alicz at anl.gov, (630) 252-9525 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	4 times Attachments 

    * DOE - HousekeepingPic.png 
    * DOE - Damaged Plug.pdf 

Hazard Issues 

    * Electricity 
Skills 

    * SAF120kd: SAFETY OBSERVATION PROGRAM Read (http://www.jlab.org/ehs/ehsmanual/manual/3700.html) Then Contact Bob May ext.7632 to arrange practical 
Distribution/Notification 

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




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