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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1150">Use of Exception to Lockout and Tagout Work Instructions Results in Violation - Hanford Richland Operations Office</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>While removing and replacing extension cords on a "Rudy Cart," used to supply temporary power to the AX Change Tent, an energized extension cord was inadvertently cut. This shorted out and tripped the Ground-Fault Circuit Interrupter (GFCI) on the cart causing it to lose power. No injuries occurred to personnel as a result of this event.
[NOTE: "Rudy Carts" at the Hanford site have electrical panels, a transformer, and Ground-Fault Circuit Interrupter (GFCI) receptacles. They are used to provide temporary power to facilities when needed.
The AX Change Tent is a temporary structure used to facilitate the safe ingress and egress for contamination control purposes for the 241-AX Tank Farm.]
</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Inside the AX Change Tent various equipment and lights are powered using extension cords plugged into GFCI receptacles on two Rudy Carts. Over time the plastic covering on the extension cords degrades (becomes brittle and cracks) due to continued exposure to weather, thus they are scheduled for periodically replacement. On April 13, 2021, maintenance on the carts was scheduled which included replacement of the extension cords on one of the carts. The work package required two Eight-Criteria Checklist Lockout-Tagouts (LOTOs) prior to removal of the carts from service.
The work crew installed the required LOTOs and completed inspections and replacement of the breakers on the carts. The Field Work Supervisor then decided to utilize an exception contained in "DOE-0336, Hanford Site Lockout/Tagout Procedure" for the cord replacement work and had the LOTOs removed. The procedure allowed for the work crew to unplug all the extension cords on the cart and then replace them; instead, the work crew unplugged and replace each cord one at a time. One of these replacement intervals caused the cart to short and trip the Ground-Fault Circuit Interrupter (GFCI).
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The direct cause of the event was found to be that the LOTO was removed prior to removing and replacing the extension cords.
Three contributing causes were identified:
- The Field Work Supervisor decided that the work package allowed for autonomy in determining how to control the electrical hazard while removing and replacing extension cords, and authorized the use of "DOE-0336, Hanford Site Lockout/Tagout Procedure."
- The workers decided not to follow the authorized procedure, which was that while the Cart was energized all extension cords were to be unplug and then replaced. Instead they replaced each separately, one at a time.
- It was not recognized that the electrician, located inside of the AX Change Tent, no longer had "exclusive control" over the energy source (male plug end).
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>The Work Control Management reviewed the event and the requirements of the procedures with the Field Work Supervisor.
The LOTO Subject Matter Expert (SME) provided the work crew with training on how to appropriately maintain exclusive control when using the "cord and plug method" to control hazardous energy.
A "Required Reading of this Lessons Learned" was issued to all Field Work Supervisors, electricians, and work control planners (including Subcontractors).
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">7/8/2021 10:36:35 AM by Bailey, Mary Jo</h5>
<pre>This was submitted to those current in:
SAF101: Be familiar with the concepts and practices of work planning and control
ESC004: Work Planning and Documentation
ESC007: Lockout/Tagout (LOTO)</pre>
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<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1150</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-1150</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">7/8/2021 10:14:43 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">7/8/2021 10:36:35 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">Hanford</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">Jerald Kinz, LOTO Technical Authority/Hazardous Energy Control SME, (509) 376-1168 or jerald_p_kinz@rl.gov</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">350</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>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6024">Hanford-ROO-LOTO.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>Other: Poor Work Planning and Communication </li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF101: Be familiar with the concepts and practices of work planning and control</li>
<li>ESC004: Work Planning and Documentation</li>
<li>ESC007: Lockout/Tagout (LOTO)</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>
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