[Hallb-engineering] Fwd: Lesson Learned "Inadequate LOTO Results in Hand Injuriy- Idaho National Laboratory"

[Douglas Tilles]

FYI

----- Forwarded Message -----
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. 
Analysis 
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. 
Recommended Actions 
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. 
Comments 
9/2/2016 7:43:17 AM by Bailey, Mary Jo 
Submitted to those with SAF603A: ELECTRICAL SAFETY AWARENESS 
	
Summary 	Lesson ID: 	962 
	Status: 	OK 
	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 
	Source: 	DOECRD 
	Location: 	INL 
	Cost Savings: 	
	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 

Hazard Issues 

    * Electricity 
    * Lock, Tag, Try 
    * Pinch Points 
    * Stored Energy: Mechanical, Hydraulic, Pneumatic 
Skills 

    * SAF603A: ELECTRICAL SAFETY AWARENESS 
Distribution/Notification 

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




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