[Hallb-engineering] Fwd: Lesson Learned "Have New Process Ideas Reviewed Before Use - Swift Staley Team"

[Douglas Tilles]

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Monday, September 12, 2016 11:00:15 AM
Subject: Lesson Learned "Have New Process Ideas Reviewed Before Use - Swift Staley Team"

Jefferson Lab Lessons Learned : Print Lesson 
	Have New Process Ideas Reviewed Before Use - Swift Staley Team 
	
Statement of Lessons Learned 
Worker-initiated improvements, while encouraged, must still be reviewed for safety. 
Discussion of Activities 
Internal surveillance uncovered an improper "improvement" for performing electrical zero-energy checks that had been passed by word-of-mouth between electricians.

NFPA 70E, section 120.1 requires an electrician to check a voltage testing device against a known energized source before and after use to confirm there is no voltage on the circuit and that the circuit had been de-energized. 

Typically, an electrician uses a nearby receptacle as the known source.  However, if the circuit is outdoors, removed from other structures, there might not be a receptacle nearby.

According to the informal "improvement," an electrician could use a 12-volt automotive battery in a work vehicle to confirm the voltage testing device is working.  The assessor noted that to do this would require the meter to be switched to the direct-current-volts (V DC) setting when measuring the battery voltage and to the alternating-current-volts (V AC) setting when testing the de-energized circuit, thus failing to check the same internal meter circuits against the known source that were used to confirm the circuit is de-energized. 
Analysis 
Workers did not question the safety of an informally developed change to a procedure related to personnel safety. 
Recommended Actions 
Ensure that all personnel understand that any safety process modifications have been reviewed and approved through the safety expert or process orwner.

Managers and supervisors are to review and emphasize the importance of bringing new ideas through the work control process before passing them on to workers.

Equip electrician�s vehicles with an approved 12V DC to 110V AC Power Inverter so appropriate verification of the voltage testing device can be made. 
JLab Preventive Measures 
This lesson learned is provided as a good work practice. 
Comments 
9/12/2016 9:12:15 AM by Bailey, Mary Jo 
Submitted to those with SAF603A: ELECTRICAL SAFETY AWARENESS 
	
Summary 	Lesson ID: 	967 
	Status: 	OK 
	Doc ID: 	2016-JLAB-967 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	9/12/2016 8:41:14 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	9/12/2016 9:12:15 AM 
	Source: 	DOECRD 
	Location: 	OTHER 
	Cost Savings: 	
	Contact: 	James Tortorelli 270-441-5030 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	2 times Attachments 


Hazard Issues 

    * Electricity 
    * 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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