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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1152">PHY-21-0721 Student Receives Two 120V Electric Shocks</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>A student received two 120V shocks because a Cannon-plug lock-ring was installed incorrectly by the manufacturer and did not "lock" the plug into place (see Photo 1). Instead the lock-ring could rotate and the "hot" channel could be inserted into the "ground" channel and energize the crate. The discovered defects were not visible at the time of the incident.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On July 21, 2021, a student was troubleshooting communications between a new computer aided engineering network (CAEN) crate and a workstation (see Photo 2). The first step was to verify that both ends of the power cord, provided by the manufacturer, were seated properly. The student verified that the plug end (Photo 3) was seated in the workstation outlet (Photo 4), then attempted to confirm that the Cannon-plug end was seated properly in the crate receptacle (See Photo 5). The student was stabilizing himself on the workstation with one hand while adjusting the Cannon-plug with the other when he felt the first shock.
While the student was unplugging the Ethernet cable, he brushed his hand over another part of the CAEN crate and experienced another shock. He promptly notified his supervisor who immediately escorted him to the Occupational Medical facility. The cable and CAEN crate were immediately locked out.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The investigation found that the power cord was defective in two ways:
1. The Cannon-plug¿s lock ring was incorrectly installed by the manufacturer. Typically, it would force the prong orientation to match three unique insertion points - hot, neutral and ground. The incorrectly positioned, rotating lock-ring allowed the "ground" to be inserted into the "hot" slot (see Photo 1).
2. Internal wiring on the plug end had been cut, presumably by the set-screw that locked the top and bottom half together (see Photo 6). This resulted in the set-screw becoming an electrical conductor.
As investigators were unable to duplicate the event it is presumed that when the student set their hand on the on the workstation rail to steady themselves, their fingers rested against the energized metal set-screw head and when they touched the Cannon-plug they became the path to ground for the voltage.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Extent of condition check identified that there were four similar CAEN crates received since March 2020. These were examined but no defects found. The Physics Division Safety Officer is identifying and checking similar equipment received during the same time frame.
The Jefferson Lab Technical Representative notified the vendor of the two failure modes, with pictures and explanation of events.
The work group requested a Qualified Electrical Worker to modify the power cord / plug assemblies to fit their needs.
</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">8/2/2021 12:26:55 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
SAF101: Be familiar with the concepts and practices of work planning and control
ESC001: Basic Electrical Safety (for Electrical Workers)</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1152</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-1152</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">7/30/2021 9:17:31 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">8/2/2021 12:26:55 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">Ed Folts, Physics Division Safety Officer, Folts@jlab.org</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">357</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">3 times</td>
</tr>
</table>
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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=6050">PHY-21-0721-Photo1.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6051">PHY-21-0721-Photo2.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6052">PHY-21-0721-Photo3.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6053">PHY-21-0721-Photo4.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6056">PHY-21-0721-Photo5.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6057">PHY-21-0721-Photo6.jpg</a></li>
</ul>
<hr>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</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>ESC001: Basic Electrical Safety (for Electrical Workers)</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>
</fieldset>
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