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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=819">Failure to Appropriately Plan Work at the Task Level Results in Electrical Shock - Lawrence Berkeley National Laboratory</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.
While working at a newly constructed building undergoing initial energization, an apprentice electrician received a 277-volt shock from an unrecognized shock hazard.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On the morning of November 19, 2013, a Plan of the Day (POD) meeting was held which reviewed electrical work. It included work to be performed by an apprentice electrician under an approved LOTO permit. The apprentice applied his lock to a group lockbox and the work was performed without incident.
Later in the day, the apprentice was tasked with terminating wires in a junction box. This work was outside the scope of work covered under the initial LOTO permit discussed in the POD meeting and initiated earlier. A pre-job briefing was held for this work, but did not cover a LOTO nor the importance of testing before touching. A pre-task hazard analysis (PTHA) was not completed, and the apprentice did not confirm whether the circuit was controlled by the LOTO used earlier in the day. During the work, the apprentice held a stripped wire in his left hand, when he touched a metal ceiling rail with his right. This initiated the shock incident.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Work planning and control on the day of the incident was inadequate. Specifically, the work being performed at the time of the shock was not planned and consequently, was not included in the PTHA, POD, nor was it covered by a LOTO process. The failure occurred primarily because work instructions were given outside of the initial work plan and control steps. This resulted in missed opportunity to properly assess and control all the work hazards.</pre>
<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. When expanding a LOTO’s scope, review the initial scope to ensure expanded boundaries are adequate controlled.
2. When conducting a pre-job briefing that covers work performed under a LOTO, always discuss the safety boundaries and the importance of verifying a zero energy state.
3. Ensure that work authorization and change control at the task level is defined clearly in work planning and control requirements, work processes and in contract language and specifications.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">4/30/2014 4:31:07 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with the following training:
SAF117: EH&S MANAGEMENT TRAINING
SAF603A: ELECTRICAL SAFETY AWARENESS</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">819</td>
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<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2014-JLAB-819</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>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Issued:</td>
<td class="dataval">4/30/2014 4:28:35 PM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">4/30/2014 4:31:07 PM</td>
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<td class="label">Source:</td>
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DOECRD
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<td class="label" nowrap>Location:</td>
<td class="dataval">LBL</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">Theresa Triplett / 510-486-7401</td>
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<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>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3020">DOE Lessons Learned - Electrical8.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>Other: Work Planning and Communication,</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF117: EH&S MANAGEMENT TRAINING</li>
<li>SAF603A: ELECTRICAL SAFETY AWARENESS</li>
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<legend>Distribution/Notification</legend>
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<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
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