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valign="top">Lesson Learned "CIO-19-0708 Employee Receives a Shock While Troubleshooting IMAC Desktop Computer"</td>
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valign="top"><strong><span
style="font-size: 18px">INTERNAL MEMO</span></strong></td>
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valign="top"><span style="font-size: 14px">
<strong>September 24, 2019</strong><br>
<strong>Sent on behalf of ESH&Q</strong><br>
<strong>SUBJECT:</strong> Lesson Learned "CIO-19-0708 Employee Receives a Shock While Troubleshooting IMAC Desktop Computer"<br>
<strong>CONTACT:</strong> cjohnson@jlab.org
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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1116">CIO-19-0708 Employee Receives a Shock While Troubleshooting IMAC Desktop Computer</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. When performing troubleshooting work, it is imperative that you consider all the associated risks and develop and implement hazard controls before you begin your work. This may include the use of specialized tools that will remove the worker from the hazard.
2. Any worker that is expected to perform service and maintenance activities on electrical equipment must be adequately trained and qualified before performing those activities. Even qualified workers must factor-in protective measures to reduce electrical shock hazards when protective covers on equipment are removed and hazardous energy may be present. If mitigation is not possible, then Lock/Tag/Try must be executed if the equipment is to be approached or manipulated.
3. It is important that when a person has been shocked or significantly injured that they are escorted to Occupational Medicine for evaluation. This ensures that if something adverse were to happen to them, there is someone there to offer immediate assistance.
4. Prior to commencing work it is good practice to walk down the job to look for any potential or existing hazards. A recent event had a worker come into contact with electrical hazards on a piece of equipment they were working where an electrical warning sign was printed on the hardware and overlooked.
5. Prior to commencing work it is good practice to review existing procedures to ensure all hazards have been addressed. A recent event had a worker come into contact with electrical hazards without reviewing existing industry standard procedures which warned of those hazards.
6. Sources of electrical hazards can be found everywhere. This includes electronic equipment in both an office and industrial settings.
</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>An Information Technology (IT) employee was troubleshooting an iMac computer that had been reported to be overheating and would not stay on. The technician unplugged the machine and discharged the components. The technician then proceeded to remove the front screen to perform a visual inspection of the inside of the machine. There were no visible signs of the machine overheating. The technician plugged in the computer and powered it on to verify that the two fans were operating properly. The technician moved their hand close to the machine's motherboard and power supply in an effort to check for air movement and heat. They inadvertently touched a soldering point within the powered computer. The technician immediately retracted their hand, and felt immediate pain in their ring finger (employee was wearing a metal wedding ring, unsure if the ring made direct contact with the solder point) that radiated into their lower forearm and also into their chest area.
The technician unplugged the machine and notified the manager and their supervisor about the event. The technician walked to Occupational Medicine for evaluation and was sent offsite for further evaluation. Later that night the technician was released from the hospital with no restrictions.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Judgement of Needs (JON): Chief Information Office (CIO) management needs to ensure that an adequate hazards analysis is performed for tasks involving powered or formerly powered equipment that affect the safety and health of personnel.
The Root Causes of the accident were: Job scoping did not identify special circumstances and/or conditions.
JON: CIO Management needs to evaluate the current training requirements of technicians.
The contributing Causes of the accident were: Training requirements were not clearly identified.
JON: CIO Management needs to evaluate the effectiveness of implementation of the training program by observing and measuring workplace performance.
The Contributing Causes of the accident were: Signs to stop were ignored, steps were performed incorrectly and individual justified action by focusing on biased evidence.
JON: ESH&Q Management needs to review the ESH Manual chapters within 6200 (Electrical and Electronics Safety) to ensure all content describing training expectations are current and consistent throughout the chapter.
The Contributing Causes of the accident were: Management policy guidance/expectations not well-defined, understood or enforced.
Extent of Condition:
An investigation into the training requirements was launched and a validation check of like task related workers in Accelerator and Engineering groups. There was a gap discovered that the JTA questions for Electrical workers may need rewording to help capture those who need the minimal training (Electronics Worker) versus the full Electrical Worker training.
ESH Manual Chapter 6200 and 6230 explain the differences between the two types of workers and the required training for each based on what Mode and Class of work they will be exposed to. The JTA questions should be geared toward hitting the target at the minimal requirements first and escalating to the appropriate level via the follow-up questions. One required minimum training requirement (SAF104 Lock, Tag and Try) is currently nested under a question that may hit the Electrical Worker but may miss the Electronics worker.
Minimum training was:
SAF104 LTT
SAF603A Electrical Safety Awareness
SAF603S Switching of Electrical Equipment
Electrical Workers would add to the above list of training:
SAF603N1 ARC FLASH:LIVE to TELL! (ELE016EFV)
SAF603N2 Electrical Safety:Beware of the Bite (ELE5EFV)
SAF603R Release from electrical contact
ESH&Q has been notified and other DSOs have been notified and are involved with the discussion of changing the JTA questions so that these requirements will be captured when supervisors assign training requirements to the various levels of Electrical Workers.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1.ESH&Q to bring to the attention of all DSOs the JTA issue and have them review and assist with crafting the JTA questions.
2.Review and edit the ESH&Q Manual chapter 6200 and its appendices to ensure that training requirements are consistent throughout the chapter and its appendices.
3. Provide appropriate review and approval of ES&H Manual Chapter 6200 and appendices.
4. Evaluate EJTA questions and correct the language within the questions to ensure that those working on electronics, such as computers and servers, are required to take the appropriate level of electrical worker training.
5. Once EJTA questions are updated, ESH&Q Management needs to communicate the requirement for all divisional management to reassess their worker's need for electrical safety training in light of the recent electrical events.
6. Evaluate how the implementation of CIO technicians training is going. Observe their workplace performance of new or revised desktop procedures and/or policies. Determine if adjustments are needed to the procedures and/or policies to mitigate existing or potential hazards.
7. CIO Associate Director will email their employees notifying them that their supervisor will adjust their EJTAs to include the appropriate electrical worker training.
8. CIO supervisors shall adjust Their worker's EJTA to reflect the required electrical worker training.
9.Develop a desktop procedure which details how to manage troubleshooting of desktop computer to include hazard analysis and user expectations. If the risk code from the hazard analysis is 2 and above, follow Environmental Safety and Health Manual Chapter 3210. This procedure will include a section that addresses the student and new employee training program by observing and measuring workplace performance.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/24/2019 9:56:30 AM by Johnson, Tina</h5>
<pre>IT fixed some issues with the delivery of the lessons learned and asked that I resend. PLEASE..review and share this information within your work groups. Emphasize that you should always escort an Injured person to Occupational Medicine. Another point of emphasis, but no less important is to ensure anyone that is working on energized equipment, have electrical worker training, even if it is a computer, laptop, copier, etc, </pre>
<h5 style="white-space:nowrap">9/9/2019 4:30:21 PM by Johnson, Tina</h5>
<pre>SME reviewed and approved the lessons learned. Please review and share this information within your work groups. Emphasize that you should always escort an Injured person to Occupational Medicine. Another point of emphasis, but no less important is to ensure anyone that is working on energized equipment, have electrical worker training, even if it is a computer, laptop, copier, etc, </pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1116</td>
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<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">2019-JLAB-1116</td>
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<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">Johnson, Tina</td>
</tr>
<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">9/9/2019 4:20:55 PM</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Johnson, Tina</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">9/24/2019 9:56:30 AM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
TJNAF NE
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<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</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">Harry Fanning</td>
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<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">446</td>
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<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">1</td>
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<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">31 times</td>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>50V or Greater: De-energized Work</li>
<li>50V or Greater: Diagnostic Type Operations</li>
<li>50V or Greater: Repair or Construction of Energized Components and Systems</li>
<li>Mode 1: Class 1, 2, and 3 Electrical Equipment</li>
<li>Mode 2: Class 1 Equipment</li>
<li>Mode 2: Class 2 and 3 Equipment</li>
<li>Mode 3: Class 1 Equipment</li>
<li>Mode 3: Class 2 and 3 Equipment</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF603: SAF603A FPA-70E BASIC ELECTRICAL TRAINING</li>
<li>SAF603A: ELECTRICAL SAFETY AWARENESS</li>
<li>SAF603N: NFPA-70E BASIC ELECTRICAL SAFETY</li>
<li>SAF604: HIGH VOLTAGE IN R&D</li>
<li>SAF603S: Switching of Electrical Equipment</li>
<li>SAF603M: NFPA-70E for Managers</li>
<li>SAF603N1: Safety Matters: Arc Flash</li>
<li>SAF603N2: Safety Matters: Electrical Safety</li>
<li>SAF603N3: Electrical Safety for the Qualified Worker (ELECEFV)</li>
<li>SAF603A.kd1: 10CFR851 Reference Changes</li>
<li>SAF603R: Release from electrical contact</li>
</ul>
</fieldset>
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<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>
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