<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html>
<head>
<title>Jefferson Lab Lessons Learned : Print Lesson</title>
<base href='https://misportal.jlab.org/ll/'>
<!--[if IE]>
<style type="text/css">
#page_content input[type=checkbox], #page_content input[type=radio] {
background-color: transparent;
border: 0;
}
</style>
<![endif]-->
</head>
<body>
<div id="doc3" class="yui-t7">
<div class='round' id='pageMessages'>
<!-- -->
</div>
<div id="lesson" class="yui-gc">
<style type="text/css">
pre {
white-space: -moz-pre-wrap;
white-space: -pre-wrap;
white-space: -o-pre-wrap;
white-space: pre-wrap;
word-wrap: break-word;
overflow: hidden;
margin-left: 10px;
}
</style>
<div id="topbar">
<div id="lesson_title">
<table width="100%">
<tr>
<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=922">Three Workers Received an Electrical Shock from a Modified Digital Macro Ring Flash - Los Alamos National Laboratory</a></td>
</tr>
</table>
</div>
</div>
<table width="100%">
<tr>
<td valign="top" width="100%">
<div id="maintextcol" class="yui-u first">
<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>For a copy of the original report, see "Attachments" on Lessons Learned page.
When working with modified equipment review the potential for stored energy. Use of appropriate tools, protective equipment, a questioning attitude, self-check, peer-check, and effective communication are important when there is uncertainty about conditions.
</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On June 9, 2015, the Shock and Detonation Physics Group reported that three workers had each received an electrical shock (similar to a carpet shock) while handling a Vivitar Digital Ring Flash modified to illuminate the target in the vacuum chamber during a gas-gun shot evolution. The Flash was spliced into the power cable of the vacuum chamber ribbon cable. It was then placed inside the vacuum chamber while the power supply was positioned outside the chamber during the gas-gun shot.
On June 2, 2015, the first worker received a shock to his left index finger while connecting the equipment. On June 8, 2015 the second and third workers each received a shock, the second to his right index finger as he made the connection between the power supply connector (in the same manner as the first worker); and the third on his finger while troubleshooting the equipment.
Later, after consulting with each other, they concluded that the perceived static electric discharge (carpet shock) was a result of the equipment. They contacted the group electrical safety officer who suspended work pending further review.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Based on the information found in the Flash's Instruction Manual, a large amount of electrical energy (about 40,000J) is typically stored in the Flash's capacitor. This stored energy is then slowly released to power other portable electrical equipment, such as a camera. It is concluded that the workers felt the residual charge left in the capacitor after the Flash had been triggered by the gas shot. (If the Flash had not been triggered it is possible that the capacitor could have discharged up to 25J.)</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.
When the workers described their "static-carpet-like" shocks they were transported to Occupational Medicine for evaluation. The three workers were subsequently released to work with no restrictions and scheduled for follow-up evaluations.
Work was suspended pending further review.
All previous modifications to electrical equipment was reviewed.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>In accordance with ES&H Manual Chapter 6240 Electronic Equipment - Construction and Modification Safety - Only those who are authorized may design modifications to electronic equipment. When it is necessary to build or modify electronic equipment it is done in accordance with 10 CFR 851 - Worker Safety and Health Program. This is achieved by assuring that final products meet the intent of applicable electrical safety standards used by Nationally Recognized Testing Laboratory(ies). </pre>
</div>
<div id="comments_div">
<a name="comments"></a>
<h2>Comments</h2>
<h5 style="white-space:nowrap">11/30/2015 9:22:02 AM by Bailey, Mary Jo</h5>
<pre>Sumbitted to those current in:
SAF104: LOCK, TAG, AND TRY
SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS</pre>
</div>
</td>
<td valign="top">
<div class="yui-u">
<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">922</td>
</tr>
<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
</tr>
<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2015-JLAB-922</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Best Practice</td>
</tr>
<tr class="row">
<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>
</tr>
<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">11/30/2015 9:19:28 AM</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">11/30/2015 9:22:02 AM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
DOECRD
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">LANL</td>
</tr>
<tr class="row">
<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
</tr>
<tr class="row">
<td class="label" nowrap>Contact:</td>
<td class="dataval">Shorty Esch, 505-665-3713, Ernst@lanl.gov</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">1 times</td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=4222">DOE - Mild Shock3 Pic.pdf</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4223">DOE - Mild Shock3.pdf</a></li>
</ul>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>Stored Energy: Mechanical, Hydraulic, Pneumatic</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF104: LOCK, TAG, AND TRY</li>
<li>SAF130A: PRESSURE SYSTEMS SAFETY AWARENESS</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>
<!--
<fieldset>
<legend>Applicable Orgs</legend>
<ul class="lesson_attribute_listing">
</ul>
</fieldset>
-->
</div>
</td>
</tr>
</table>
<script language="javascript">
var commentTextarea = document.getElementById("commentForm:commentText");
if (commentTextarea){
var validationErrorFound = commentTextarea.parentNode.innerHTML.indexOf("Validation Error: Value is required.") > -1;
if (validationErrorFound){
// add hash if necessary
if (window.location.hash == null || window.location.hash == "" || window.location.hash == "#"){
window.location.hash = "#comments";
}
}
else {
//JSF likes to hold on to the values entered into the form...so blank them out
commentTextarea.value = "";
commentTextarea.form.elements["commentForm:commentType"].selectedIndex = 0;
var numStars = commentTextarea.form.elements["commentForm:stars"].length;
for (var ii=0; ii<numStars; ii++){
commentTextarea.form.elements["commentForm:stars"][ii].checked = false;
}
}
}
</script>
</script>
</div>
<br>
<br>
</div>
</body>
</html>
<br>
<br>
Do you have a lesson learned you would like to contribute? Contact the <a href="mailto:sjsmith@jlab.org,mbailey@jlab.org,cjohnson@jlab.org">Lesson Learned Coordinator</a>.