[Hallb-engineering] Fwd: Lesson Learned "Research Assistant Shocked as a Result of Worn Heat Tape � Pacific Northwest National Laboratory"
tilles at jlab.org
Thu Mar 10 10:01:03 EST 2016
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From: "mbailey" <mbailey at jlab.org>
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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
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.
/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.
3/10/2016 9:50:28 AM by Bailey, Mary Jo
Submitted to those with SAF603A Electrical Safety Awareness training
Summary Lesson ID: 935
Doc ID: 2016-JLAB-935
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
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
* SAF603A: ELECTRICAL SAFETY AWARENESS
* *Division Safety Officers (DSOs)
* *Safety Wardens
* *DOE Notification
* *ESH&Q Liaisons
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