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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1154">ACC-21-0809- Employee Received 120 Volt Shock While Unplugging Equipment-No Injuries </a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>During a routine operations check a GFCI outlet box (see Photo 1) was found to have tripped for no apparent reason. It was re-set without issue. Later, condensation, from an overhead LN2 piping and valve assembly, was observed dripping onto the box (see Photo 2). The situation was not considered an emergency and a Priority 1 Work Order was submitted to Facilities Management and Logistics (FM&L). As a precaution it was decided to unplug all electrical cords from the GFCI outlet box until repairs could be made. When removing the last cord from the box, the operator experienced an electrical shock travel from the right hand, up the right arm, and terminate in the right pectoral muscle region. The operator contacted their supervisor and Occupational Medicine and was directed to the local emergency facility and later discharged with no restrictions.
<img src=" https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6064" width="250px"> <img src=" https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6065" width="250px"></pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On August 9, 2021 an operator was performing a common procedure that, after set-up, normally runs unattended, requiring only occasional checks to ensure proper performance. During one of the checks it was discovered that the GFCI outlet box had tripped. Seeing no abnormal conditions at the time, the operator resets the GFCI, and continued the program. Near the end of the shift, while shutting down the equipment, the operator noticed water (condensation) dripping down from the overhead liquid nitrogen piping. Thinking this might be why the GFCI outlet had tripped earlier, the operator took pictures of area to record the conditions (see Photos 1, 2, 3 and 4) and submitted a priority work order to FM&L.
<img src="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6066" width="250px"> <img src="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6067" width="250px">
After about 1.5 hours, the operator concluded that FM&L might not respond until the next day. The situation was not considered an emergency since water was no longer dripping, but not wanting to leave the equipment at risk it was decided to unplug the cords from the GFCI outlet box. Three plugs were pulled without incident. When pulling out the fourth the operator experienced a shock travel up his right arm and shoulder to his pectoral muscle. The operator then looked at the fourth plug and found there was water on the prongs (see Photo 5).
<img src="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6068" width="250px">
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The insulation installed on the LN2 piping was not effective as a control (barrier) against the formation of condensation. Either the process owner(s) or subcontractor chose insulation material inappropriate for the application, or installed the insulation poorly, leaving gaps where exposed, below dew point pipe surfaces could condense water from the ambient air of the area.
Because of the recent tripping of the GFCI breaker, the later observation of condensation dripping onto the electrical outlet box and cords, and the submitting of a Priority 1 work order, the situation should have continued to be recognized as high-risk. However, the operator proceeded to dismissed the hazard as no additional GFCI trips had occurred, condensation was no longer visible, and a work order had been placed.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>The operator was escorted to the local emergency facility and later discharged with no restrictions.
FM&L immediately secured the scene and locked out the breaker. The GFCI was tested, but found to be working properly.
FM&L replaced the GFCI electrical box with IPX-rated waterproof cover and conduit (see Photo 6).
<img src="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6069" width="250px">
A work plan is being developed to reconfigure the overhead liquid nitrogen piping to protect against accumulating condensation.
This event will be incorporated into the training module as an anticipated hazard recognition example.
</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">9/14/2021 1:56:50 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those having
ESC001: Basic Electrical Safety (for Electrical Workers)</pre>
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<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1154</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-1154</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">9/14/2021 1:37:55 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">9/14/2021 1:56:50 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">Harry Fanning, Acceleratory Division Safety Officer (Fanning@jlab.org)</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">341</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>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6064">Photo 1 - ACC-21-0809.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6065">Photo 2 - ACC-21-0809.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6066">Photo 3 - ACC-21-0809.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6067">Photo 4 - ACC-21-0809.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6068">Photo 5 - ACC-21-0809.jpg</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=6069">Photo 6 - ACC-21-0809.jpg</a></li>
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<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>ESC001: Basic Electrical Safety (for Electrical Workers)</li>
</ul>
</fieldset>
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<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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