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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=810">Discovery of an Unexpected Energy Source after Replacement of a Circuit Relay - UT-Battelle, LLC / Oak Ridge National Laboratory (ORNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>For a copy of the original report, see Attachments on Lessons Learned page.
Although electrical systems configuration drawings are required to be maintained, field circuits may not always be configured according to associated drawings. Additional precautions should be taken and methods used to protect the worker.
</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On October 28, 2013, a qualified electrical worker replaced a 120 volt circuit relay after performing Lock-Out/Tag-Out (LOTO) at the breakers indicated on drawings and as labeled on the equipment. A zero energy check was performed at the relay’s electrical contacts indicating zero voltage.
The LOTO and zero energy check were performed in accordance with ORNL procedures.
After establishing electrical safe working conditions, the prescribed PPE was no longer required and was removed. The worker installed the new relay and performed standard post-maintenance testing. The tests included continuity testing to ensure the relay was operational. The results indicated a potential short. The worker met with the facility electrical engineer to discuss the results. After discussion, the worker returned to the relay box and depressed the relay test button to determine if the new relay was defective. This action resulted in the breaker tripping as designed; indicating voltage was present on the circuit and had been present during the work activity as opposed to the relay being defective. Line management was immediately notified.
Preliminary investigation indicated a possible problem with the contacts within the original relay which masked the presence of the 120 volt source during the zero energy check. In addition, the equipment labeling and drawings were incorrect.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause analysis concluded that (1) the circuits had not been installed per the design, (2) design prints reflected a configuration contrary to the installation, and (3) faulty installation of relay wiring (insulation still on wire causing inadequate contact with relay connections) caused the electrician to read incorrect voltage readings on the relay terminals.
Contributing Causes were (1) weaknesses in inspection and acceptance testing methods and that (2) while qualified personnel performed zero energy checks, no other means of verifying zero energy at the terminals was utilized (such as use of a proximity checker in conjunction with digital voltmeter).
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Below are the consequences of the above event. They are provided for information and discussion purposes only.
1. Verification of installations should include a more rigorous and thorough inspection and acceptance testing process.
2. Configuration drawings should reflect actual "as built conditions" verified by testing to be correct.
3. Zero energy checks should utilize approved for use voltmeters. These zero energy checks should also consider the use of addition testing methods/apparatus such as proximity testers.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">4/17/2014 10:17:37 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those with the following training:
•SAF603A: ELECTRICAL SAFETY AWARENESS
•SAF603N3: Electrical Safety for the Qualified Worker (ELECEFV)
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<legend>Summary</legend>
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<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">810</td>
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<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2014-JLAB-810</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
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<td class="label" nowrap>Safety Related:</td>
<td class="dataval">YES</td>
</tr>
<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">4/17/2014 10:16:02 AM</td>
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<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">4/17/2014 10:17:37 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
DOECRD
</td>
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<td class="label" nowrap>Location:</td>
<td class="dataval">ORNL</td>
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<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
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<td class="label" nowrap>Contact:</td>
<td class="dataval">Richard Griffey, griffeyrm@ornl.gov</td>
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<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Viewings:</td>
<td class="dataval">2 times</td>
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<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=2941">M:\wcd\LessonsLearned\DOEOEC\DOE Lessons Learned - Electrical7.pdf</a></li>
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</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>Stored energy >10 joules, capacitive, inductive, or battery</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF603A: ELECTRICAL SAFETY AWARENESS</li>
<li>SAF603N3: Electrical Safety for the Qualified Worker (ELECEFV)</li>
</ul>
</fieldset>
<fieldset>
<legend>Distribution/Notification</legend>
<ul class="lesson_attribute_listing">
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
</ul>
</fieldset>
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