[Hallb-engineering] Fwd: Lesson Learned "Inadequate LOTO Results in Hand Injuriy- Idaho National Laboratory"
tilles at jlab.org
Fri Sep 2 11:00:20 EDT 2016
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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Friday, September 2, 2016 9:00:05 AM
Subject: Lesson Learned "Inadequate LOTO Results in Hand Injuriy- Idaho National Laboratory"
Jefferson Lab Lessons Learned : Print Lesson
Inadequate LOTO Results in Hand Injuriy- Idaho National Laboratory
Statement of Lessons Learned
This event emphasizes the importance of identifying all hazards of an activity and determining the optimum safe method(s) to isolate, mitigate or appropriately control those hazards. This is particularly important when working with a combination of hazardous energy (electrical) and moving parts (mechanical), or any combination of the two.
Discussion of Activities
On June 15, 2016, a subcontract mechanic was performing preventive maintenance on an air handler. The worker had isolated the fan's electrical power through a simple Lockout/Tagout (LO/TO) of the variable frequency drive (VFD) and observed the fan slow to a stop. While attempting to remove the belt guard, the mechanic placed his hand on the belt system to brace himself. Because of the pressure, the fan started to rotate and the worker's hand was pulled in between the belt and the pulley system.
The resulting injury consisted of trauma to the right hand including a broken bone in the ring finger.
The LO/TO isolated only the electrical energy for the fan and did not address the potential hazard of unexpected movement, in this case, from pressure differential or draft through the area.
Below are the consequences of the above event. They are provided for information and discussion purposes only.
The worker manually reversed the belt to release his hand and reported his injury to his co-worker, who notified the supervisor. The supervisor called 911 and Facilities and Site Services management.
JLab Preventive Measures
Jefferson Lab has a robust hazard identification process imbedded within its work planning tools (e.g. ATLis, and similar). These processes are supported by ES&H Manual Chapter 3210 Work Planning, Control, and Authorization Process.
As part of its Lock, Tag, Try (LTT) Processes (outlined within ES&H Manual Chapter 6110 Appendix T1 Lock, Tag, Try Procedure) Jefferson Lab considers multiple energy sources during every LTT. This step is so important that it is included as a separate process step to be performed prior to commencement of work.
9/2/2016 7:43:17 AM by Bailey, Mary Jo
Submitted to those with SAF603A: ELECTRICAL SAFETY AWARENESS
Summary Lesson ID: 962
Doc ID: 2016-JLAB-962
Priority: Best Practice
Safety Related: YES
Originator: Bailey, Mary Jo
Issued: 9/2/2016 7:34:32 AM
Approved By: Bailey, Mary Jo
Approved On: 9/2/2016 7:43:17 AM
Contact: Dwight Stevenson, Idaho National Laboratory 208-526-2840
Queued Emails: 0
Sent Emails: 0
Viewings: 1 times Attachments
* DOE - Fan.pdf
* ES&H Manual Chapter 6110 Appendix T1 Lock, Tag, Try (LTT) Procedure
* ES&H Manual Chapter 3210 Work Planning, Control, and Authorization Process
* Lock, Tag, Try
* Pinch Points
* Stored Energy: Mechanical, Hydraulic, Pneumatic
* SAF603A: ELECTRICAL SAFETY AWARENESS
* *Division Safety Officers (DSOs)
* *Safety Wardens
* *DOE Notification
* *ESH&Q Liaisons
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