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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1128">ACC-20-0210 Employee Receives Shock While Plugging in Equipment at VTA</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. When design or scope changes occur perform a thorough assessment to understand potential hazards and communicate them.
2. Never reach blindly into or behind equipment that is powered up.
3. Do not energize equipment until it has been inspected and certified for use.
4. Place property management inventory tags on the front of all equipment to make annual property validation access easier. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On Monday February 10, 2020, at approximately 10:25 AM a scientist in the Superconducting Radiofrequency (SRF) group was performing a personal property validation of a modular electronic unit that serves as a low voltage input for sensors cables (temperature probes, magnetic field strength sensors, etc.). In order to see the property tag the unit was removed from an electronics rack in the Vertical Test Area of the Test Lab.
To reinsert the unit back into the rack, the scientist had to reattach a 12Vdc low voltage molded power cable located on the back of the unit. While reaching behind the unit the base of their palm came into contact with the input terminals of a separate 120VAC power supply unit, also located within the cabinet but not visible to the scientist. The scientist did not anticipate the presence of exposed conductors, low voltage or otherwise.
The scientist notified the electrical safety lead for the SRF group, and was promptly escorted to the on-site Occupational Medicine clinic for a physical evaluation. The scientist was released back to work with no injuries or work restrictions.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>1. Qualified Electrical Workers (QEW) expectations are not formalized. This includes aspects such as:
- Ensuring that the QEW have a complete understanding of ES&H Manual Chapter 6200 Electrical Safety series which includes ESH Chapter 6240 Electronic Equipment - Construction and Modification Safety and the hazard review process.
- Conducting formal design reviews and approvals of all modified electrical equipment, including specific labeling requirements.
2. Inadequate work control methods were used to communicate (request and manage) man power, prioritization of work, and progress of approved work.
4. The electrical safety awareness training lacks instruction on blind reaching and obstructed view, in accordance with NFPA70E 130.6 (B) and 130.6 (C)(2).
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1.The Directors of the Accelerator, Physics, Engineering, and Facilities Management Divisions shall form a team to reconstitute a Standard Practice for Engineered Controls for TJNAF Electrical and Electronics Equipment. The standard practice shall define the minimum set of engineered controls required for electrical and electronics equipment designed, integrated, procured, modified and installed by JSA. The standard practice should follow the example Unlisted Electrical Equipment Program described in Appendix C of DOE-HDBK-1092-2013 and incorporate the safety related design requirements in Informative Annex O of NFPA 70E (2015).
2. Accelerator Division shall evaluate work planning and control processes across work centers to ensure lab established protocols for multi-divisional activities are followed, to include practices for manpower requests, prioritization of work, and uniformity across work centers.
3. Authority Having Jurisdiction and Electrical Safety Committee to review the report generated from NE-2019-05-07-02 and develop specific policies, procedures and training content to implement the new requirements within the electrical safety program and among the Qualified Electrical Worker population and supervisory oversight.
4. Update manual chapter 6200 and the relevant appendices with language from NFPA70E 130.6 (B) and 130.6 (C)(2) .
5. Update relevant training with language from NFPA70E 130.6 (B) and 130.6 (C)(2) .
6. Train all the QEWs to the new content in the Jefferson Lab electrical safety awareness training course.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See above </pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">4/14/2020 8:29:48 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those with Electrical Safety training.</pre>
<h5 style="white-space:nowrap">4/13/2020 7:11:39 PM by Johnson, Tina</h5>
<pre>Please review and approve for distribution. SME approved the content.</pre>
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<div class="yui-u" id="lesson_info">
<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1128</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">2020-JLAB-1128</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">4/9/2020 2:04:43 PM</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">4/14/2020 8:29:48 AM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/FINAL%20ACC-0210-20.pdf" target="_blank">TJNAF NE</a>
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</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">Randy Michaud</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">501</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">12 times</td>
</tr>
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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=5724">Rack #6.jpg</a></li>
</ul>
<hr>
</fieldset>
<fieldset>
<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>
</ul>
</fieldset>
<fieldset>
<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>
<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>
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