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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1133">Uncontrolled Electrical Hazard Discovered in Fume Hood - Pacific Northwest National Laboratory (PNNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Earlier in 2020 an uncontrolled electrical hazard was discovered on a furnace that was to be installed in a fume hood at PNNL. Prior to installation, the furnace was left with its top panel removed exposing electrical components greater than 50 volts. It was left unplugged and unattended with its cord unsecured so it could be plugged into any outlet.
(For more details see the attached "PPNL Electrical Hazard Summary.pdf")</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>In 2018, research staff determined their fume hood required more heat to support their project. A new furnace was procured in 2019 and delivered, however modifications to the fume hood and furnace were required before it could be installed. A service request was prepared, which covered the specific modifications needed. The request did not specify that the old furnace's cover was to be used to enclose the new furnace's exposed electrical components, nor the specifics of who was responsible for installation.
In January 2020, research staff moved the now modified furnace nearer the fume hood to prepare for installation. A few days later electricians installed the wiring. The intent to re-use the old furnace's cover to protect the exposed electrical components was not discussed. The electricians finished their defined tasks and left the furnace unplugged with the electrical components exposed. Their mindset was that the furnace was not yet commissioned for use and everyone in the area knew this, so no one would plug it in.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>An analysis of this event revealed that the researchers did not clearly define the job's scope, and the electricians did not question the work sequencing nor the end-state of the equipment.
Collaborative conversation during job scoping is critical in defining and understanding work scope, manufacturer equipment installation instructions, task performance expectations, task interruptions and duration, as well as the end-state of the equipment.
During work planning meetings review details regarding each step of the work, the duration, the end use plan, and specifics on responsibilities. This could reduce the likelihood of human error.</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>PNNL revised their Lockout/Tagout and other electrical safety exhibits as well as various training materials to increase employee awareness and understanding of alternative methods of hazardous energy control for servicing and maintenance.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>ES&H Manual Chapter 6110 Lock, Tag, Try Program (https://www.jlab.org/ehs/ehsmanual/manual/6110.html) defines Jefferson Lab's approved method for securing hazardous energy sources to provide personal protection while performing maintenance and service work. LTT is required whenever there is the potential for someone to be injured by the unexpected start-up of equipment or by a release of stored energy during maintenance and service work. </pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">11/13/2020 10:53:42 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
SAF104A: LOCK & TAG PART I
SAF603N3: Electrical Safety for the Qualified Worker (ELECEFV)</pre>
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<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1133</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-1133</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">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">11/13/2020 10:36:57 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">11/13/2020 10:53:42 AM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
OTHER
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">PNNL</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">Laura Valett, PPNL Operating Experience Program Manager, 509-372-4959.</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">337</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>
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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=5804">PPNL Electrical Hazard Summary.pdf</a></li>
</ul>
<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>Lock, Tag, Try</li>
<li>50V or Greater: Diagnostic Type Operations</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF104A: LOCK & TAG PART I</li>
<li>SAF603N3: Electrical Safety for the Qualified Worker (ELECEFV)</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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