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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1136">Improper Lockout/Tagout Contributes to a Potential Exposure - Brookhaven National Laboratory (BNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Prior to the installation of two new groundwater treatment extraction wells, damaged 24-V communication wires needed to be removed from several existing wells. The damaged wires were co-located in the same pull boxes with 480-V insulated wiring. (See photos in the attachment). A group lockout/tagout (LOTO) was applied to the system by contract employees. Later it was found that a BNL qualified electrical worker, working on the project, did not affix his personal lock as required. There was no electrical shock or injury associated with this event, however, there was a potential for worker exposure to uncontrolled hazardous electrical energy.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>The qualified electrical worker received guidance from the Electrical Engineer that complied with the "Lifting Wires Instead of Locking/Tagging Disconnects" document. It was believed that lifting the wires was compliant with the hierarchy of controls and would eliminate the hazard. The LOTO Subject Matter Expert was not consulted. From past experience, the qualified electrical worker had performed similar work where lifting wires instead of locking/tagging disconnects was authorized, so did not question the guidance provided by the Electrical Engineer and performed the work in a similar fashion.
Meanwhile, the contract workers, who infrequently performed LOTO at the site, followed the guidance given by site employees expecting the direction to be compliant with all requirements. This led the contractors to perform the LOTO incorrectly. They did not produce a documented LOTO plan as required, so there was none available at the site.
The work manager was aware of the BNL Electrical Safety Committee's document interpretation relating to lifting wires instead of LOTO disconnects. However, the manager's follow- up activities did not identify a problem with the confusion. The manager's expectation was that staff would comply with the laboratory requirements until the confusion was addressed and resolved.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>At Brookhaven when there are multiple energy sources or multiple workers from multiple crews affected by work activities the "Installation, Demolition, or Service and Maintenance Subject Area Lockout/Tagout (LOTO) Procedure," takes precedent. This requires a documented complex LOTO plan be available at the work site. A LOTO plan should have been established once multiple LOTO sources were identified.
Less than adequate management led to a work practice that was inconsistent with the requirements of the BNL Hazardous Energy Control Process. Specifically, there was confusion regarding the requirements of lifting wires as a means of establishing an electrically safe work environment. This resulted in the contractor employees performing an inadequate LOTO and the qualified electrical worker not applying their lock or tag. </pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>- Publish the Policy on Lifting Wires in the Lockout/Tagout (LOTO) for Installation, Demolition, or Service and Maintenance Subject Area.
- Provide equipment specific LOTO procedure training to workers and assigned staff.
- For Electrical Supervisors, and Electrical Safety Advisors; provide a briefing on the Policy for Lifting Wires as described in the LOTO for Installation, Demolition, or Service and Maintenance Subject Area.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>ES&H Manual Chapter 6110 Lock, Tag, Try (LTT) Program defines the approved method for securing hazardous energy sources to provide personal protection while performing maintenance and service work. This program satisfies the requirements of OSHA 29 CFR1910.147 The Control of Hazardous Energy (Lockout/Tagout); the standard used when servicing and maintaining equipment/systems.
Jefferson Lab's construction subcontractors follow OSHA 29 CFR1926 Safety and Health Regulations for Construction; which is the standard for construction work activities. Subcontracting Officer's Technical Representatives (SOTRs) are tasked with reviewing subcontractors programs for compliance.
</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">1/29/2021 11:04:18 AM by Bailey, Mary Jo</h5>
<pre>This was provided to those current in:
SAF104A: LOCK & TAG PART I
ESC007: Lockout/Tagout (LOTO)</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1136</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">2021-JLAB-1136</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Caution</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">1/29/2021 10:56:03 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">1/29/2021 11:04:18 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">BNL</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">Jean Odin-McCabe, Institutional Lessons Learned Coordinator 631-344-6055 or odin@BNL.gov</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">302</td>
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<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Viewings:</td>
<td class="dataval">1 times</td>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=5824">Brookhaven 01'21.pdf</a></li>
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<hr>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>Lock, Tag, Try</li>
<li>Other: Poor Work Planning and Communication </li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF104A: LOCK & TAG PART I</li>
<li>ESC007: Lockout/Tagout (LOTO)</li>
</ul>
</fieldset>
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<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
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