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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=950">Personnel Performing Work in an Electrical Control Panel Without Proper Hazard Mitigation ¿ Idaho National Laboratory</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Personnel, assigned to verify "as-built" drawing discrepancies noted
during recent work activities in the area, where verifying a
configuration control panel for an exhaust system that was found to have been
upgraded and labeled as having "No Exposed Electrical Hazards."
After removing the cover, a conductor with a frayed end was
discovered.This led back to a 24V relay. At the time, an
Instrumentation & Calibration (I&C) Technician entered the room while on
another job. Personnel discussed the situation with the I&C Technician
and requested the removal of the frayed end and installation of a
wire nut. I&C Technician removed the 24V relay and cut off the frayed
end of the wire, He then re-installed the relay.
Personnel notified their supervisor of the pre-condition and the actions
taken.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Because the panel had been previously evaluated as having "No Exposed
Electrical Hazards" personnel exposed themselves to unnecessary
hazards.These include:
·Failure to stop work when an abnormal conditions was found,
·Failure to notify supervisor prior to taking action.
·Failed to mitigate the potential hazard when removing the frayed end of
the wire.
·Poor configuration management upon project turnover.
·Personnel incorrectly perceived an urgency to remedy the situation
immediately.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Personnel should have performed the following prior to reconfiguring the
panel.
·Exercise Time Out/Stop Work when conditions are not as expected.
·Ensure management is properly notified *prior* to taking actions.
·Ensure hazards are mitigated prior to proceeding.
·For panels that have previously been evaluated as <50VAC, Trust but
*VERIFY* the voltages are truly <50 volts within the panel prior to
performing work.
·Enhance communication for work expectations, including when to stop and
notify, questioning attitude, and ensure job expectations are clearly
understood. If the job cannot be performed within the guidelines/tools
set forth by your supervisor, then communicate this with your supervisor.
·Configuration control/drawing acceptance was inadequate for the NORESCO
Energy Systems Performance contract upgrades performed in SSPSF.
·The process for evaluating the operator access to electrical cabinets
should be reviewed to determine if improvements are needed.</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. /
Realizing that this work had been performed outside of the approved work
control for this activity the Supervisor called a time out and notified
Facility Management,
Subsequent inspection by Facility Management and the I&C Technician
revealed there was exposed 120VAC inside the cabinet.No voltage was
present at in cut wire.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>(Jefferson Lab¿s Subject Matter Expert has provided the statement below.)
"With any type of work, Jefferson Lab's policy is that when your encounter a change in the original scope, stop and re-evaluate for any new hazards and apply mitigation(s) needed before re-starting the work."</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">6/3/2016 8:02:01 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those with 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">950</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">2016-JLAB-950</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
</tr>
<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">NO</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">6/3/2016 7:55:46 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">6/3/2016 8:02:01 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">INL</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">Robert Gomez, SSPSF NFM 866-495-7440</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">5 times</td>
</tr>
</table>
</fieldset>
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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=4464">Control Panel - INL.pdf</a></li>
</ul>
<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>Other: Work Planning and Communication,</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF603A: ELECTRICAL 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>
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Do you have a lesson learned you would like to contribute? Contact the <a href="mailto:mbailey@jlab.org,sjsmith@jlab.org,cjohnson@jlab.org">Lesson Learned Coordinator</a>.