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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1141">ENG-20-1014 Failure to Identify Potential Energy Source and Apply LO/TO</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>During a transformer replacement in a radio-frequency (RF) cabined it was found that an insulating protective cover inside the cabinet had been installed (reinstalled) upside down, leaving electrical lug feeds insufficiently guarded. The RF cabinet was under a compliant lock-out/tag-out (LO/TO) configuration having been applied by a qualified electrical worker in accordance with the standard procedure, however, the main distribution panel (MDP) circuit was not under a hazardous energy control (danger) LO/TO. This condition resulted in the worker having no personal control over the electrical circuit feeding the cabinet, which represents a near-miss condition.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On October 14, 2020, while performing a routine electrical safety inspection two electrical safety inspectors confirmed that a breaker mounted to the front panel of a RF cabinet was under a compliant lock-out/tag-out (LO/TO) configuration and the lock and tag had been applied by a qualified electrical worker in accordance with the standard procedure. However, further inspection revealed that the electrical lugs feeding the cabinet were exposed due to the improper installation of an insulating protective cover. The main distribution panel circuit (480V, 200 amp) feeding the cabinet was not under a hazardous energy control (danger) LO/TO, though it was found in the "OFF" position. The worker performing the overhaul activities was not aware of the exposed nature of the electrical feed, nor had they confirmed the state of the upstream electrical breaker before undertaking work inside the cabinet. </pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The approved standard procedure being used for the work activity presumed all guards would be intact and installed properly. However, because the insulating protective cover had been installed (or reinstalled) upside down the hazard was insufficiently guarded.
There were three separate groups working in the same area on connected systems. Each group was responsible for creating work plans independently with a focus on their specific tasks. The work plans were then coordinated through the accelerator operability manager. All groups scheduled their work according to the Accelerator (ATLis) work planning system, however, the work details for each were inconsistent.
The main distribution panel servicing the RF cabinet had recently been replaced within the relevant work cycle by another work group. A pre-job walk-down with all groups involved did not happen, so the RF group was not made aware, nor did they anticipate the new configuration feeding to the RF cabinet.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>A "suspend work" condition was put in place by Division leadership pending an extent of condition review.
The work control document was modified to require inspection of the internal guarding to ensure it is in place and properly configured.
Change(s) were made to the work control document to initiate a lockout at the main distribution panel to eliminate the possibility for lead side power to the equipment during work.
An "Installed Engineered Safety Measures Extent of Condition Check" for ALL class 2-3 electrical/electronic equipment is to be initiated. This step (checkbox) is to be added onto the work control document form to require equipment be inspected prior to initiating access.
Publish a Lab-wide Safety Flash outlining the additional guard inspection step as a feature to be included in all similar work control documents.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See above recommended actions.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">3/22/2021 1:54:28 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with:
SAF603: Understand the basics of electrical safety</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1141</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-1141</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">3/22/2021 1:47:12 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">3/22/2021 1:54:28 PM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
TJNAF NE
</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">Ken Baggett Engineering Div, Baggett@jlab.org </td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">495</td>
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<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>Electricity</li>
<li>Other: Poor Work Planning and Communication </li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF603: Understand the basics of electrical safety</li>
</ul>
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<legend>Distribution/Notification</legend>
<ul class="lesson_attribute_listing">
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*ESH&Q Liaisons</li>
<li>*DOE Notification</li>
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