[Hallb-engineering] Fwd: Lesson Learned "Research Assistant Shocked as a Result of Worn Heat Tape � Pacific Northwest National Laboratory"

[Douglas Tilles]

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Thursday, March 10, 2016 10:00:08 AM
Subject: Lesson Learned "Research Assistant Shocked as a Result of Worn Heat Tape � Pacific Northwest National Laboratory"

Jefferson Lab Lessons Learned : Print Lesson 
	Research Assistant Shocked as a Result of Worn Heat Tape � Pacific Northwest National Laboratory 
	
Statement of Lessons Learned 
Temporary patching of equipment may save money in the short-term, but 
can create hazards if accepted as a permanent solution, and may cost a 
project more money in the long run. Temporary material, such as tape, is 
not meant to withstand normal wear and tear from reuse, or application 
for extended periods of time. 
Discussion of Activities 
During a bio-oil system startup test, a research assistant noticed that 
one of his equipment�s temperature controllers was not heating up. He 
proceeded to reach around the system�s manifold to troubleshoot the 
problem. The manifold was wrapped in fiberglass insulated heat tape; 
however this material was frayed from repeated use exposing the 
manifold�s electrical lead. When the research assistant reached around he 
brushed his arm against the exposed electrical lead, thus receiving an 
electrical shock. 
Analysis 
The system underwent an electrical inspection prior to startup, but the 
potential electrical hazard associated with worn heat tape was not 
understood by the research assistant.

The heat tape used was recycled from a prior project (maybe several) and 
had been wound and rewound, more than a dozen times, on the current test 
system.This resulted in the fraying of the fiberglass insulation.

The heat tape was applied to protect from shock hazards. It was 
insulated with fiberglass, which is fragile, and became worn over time 
resulting in exposed hazardous energy sources.

The added protection of a GFCI (while suggested but not required by the 
manufacturer) was not present on the system.This would have reduced the 
electrical shock hazard. 
Recommended Actions 
/Below are the consequences of the above event.They are provided for 
information and discussion purposes only. /

The research assistant received a full medical evaluation and was 
released for work.

Researchers, Cognizant Space Managers, and Technical Group Managers were 
appraised of the following requirements:

Use a standard operating procedure (SOP) to prevent the need to 
troubleshoot the system. Reinforce the use of SOPs within Routine 
Operating Envelopes. Clearly state that SOPs are expected to be read and 
understood prior to commencement of work.

Check equipment prior to use. If your equipment is regularly reused, 
reinstalled, or moved, it has a higher risk for failure. Dispose of, or 
replace, equipment showing signs of  degradation.

Protect heat tape leads on all equipment. Consider wrapping 
fiberglass-insulated electrical leads with a secondary layer of 
fiberglass tape for additional protection.

Evaluate the need for GFCIs for heaters. GFCIs are recommended on heat 
tapes and heaters with fragile electrical insulation.

Be aware of time and schedule pressure. This project team was focused on 
reducing project costs and meeting deadlines.This contributed to the 
decision to reuse old heat tape, leaving the project open to additional 
risks and hazards. 
JLab Preventive Measures 
(Jefferson Lab�s Subject Matter Expert has read and provided the 
following prevention recommendation.)

1) Consider using GFCI (ground-fault-circuit-interrupter) protection with heat tapes, even if not required by the manufacturers installation instructions.

2) De-energize heat tapes before manipulating them or the equipment/system containing heat tape circuits.

3) Remember that doing a non-electrical task on an energized piece of equipment still may present an electrical hazard. 
Comments 
3/10/2016 9:50:28 AM by Bailey, Mary Jo 
Submitted to those with SAF603A Electrical Safety Awareness training 
	
Summary 	Lesson ID: 	935 
	Status: 	OK 
	Doc ID: 	2016-JLAB-935 
	Priority: 	Info 
	Safety Related: 	NO 
	Originator: 	Bailey, Mary Jo 
	Issued: 	3/10/2016 9:47:52 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	3/10/2016 9:50:28 AM 
	Source: 	DOECRD 
	Location: 	PPPL 
	Cost Savings: 	
	Contact: 	Patti Ammonet, Lessons Learned/Operating Experience Program Manager (509)375-2275 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

    * DOE - Mild Shock4.pdf 

Hazard Issues 

    * Electricity 
Skills 

    * SAF603A: ELECTRICAL SAFETY AWARENESS 
Distribution/Notification 

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




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