Theres No Shortage of Electrical Events Lessons Learned at BNL and Beyond

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Theres No Shortage of Electrical Events
Lessons Learned at BNL and Beyond!

• Edward A. Sierra
• Quality Management Office
• Presented to
• ALD for ESHQ
• Safety Health Services Division Manager
• Lab Electrical Safety Committee
• August 30, 2006

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AGENDA

• Point to Ponder
• Why this Presentation?
• DOE Electrical Safety Report 2004
• BNL Electrical Occurrences, 2002 2006
• Causes
• BNL Lesson Learned Statements
• Electrical R ORPS Reports in the Complex
• Causes
• DOE Suggested Measures to Prevent Electrical
  Occurrences
• DOE Special Operations Report, Electrical Safety
  2006
• Mandated Response
• BNL World-Class in Electrical Safety?
• Beyond BNL, Electrical Safety Programs
• Path Forward

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Point to Ponder

• Organizations only improve where the truth
  is told and the brutal facts confronted.
• - Jim Collins
• Good to Great, 2001

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Why this Presentation?

• As directed by the Deputy Director of Operations
• The Laboratory will evaluate the DOEs ORPS and
  lessons learned-databases concerning all previous
  electrical events to identify lessons learned.
  In addition, a search will be made for electrical
  safety best practices within the DOE complex.
  The results of this evaluation/search will be
  presented to the ALD for ESHQ, the Safety and
  Health Services Division Manager, and the
  Laboratorys Electrical Safety Committee for them
  to assess the applicability to BNL. 

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DOE Electrical Safety Special Report
2004-02Four Types of Electrical Safety
Occurrences

• Electrical safety occurrences are the most
  frequently reported near miss events across the
  DOE complex, and thus pose the greatest risk to
  workers.

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DOE Electrical Safety Special Report,
2004-02Four Types of Electrical Safety
Occurrences

• 1. Electrical Work Near Misses - while
  performing electrical maintenance, repair, or
  installation functions.
• 2. Electrical Intrusion Near Misses -
  during excavation and decommissioning and
  decontamination work.
• 3. Vehicle Near Misses - striking overhead
  electrical power lines, etc.
• 4. Other Electrical Near Misses -
  non-electrical workers who suffer shocks, etc.,
  during routine work performance.ROOT CAUSES
  largely stemmed from basic conduct of operations
  deficiencies
• Work Planning
• Lockout/Tagout
• Configuration Management

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Complex Workers Involved in 2002-2003Electrical
Safety Occurrences
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17 BNL Electrical Safety Occurrences2002-2006

• 2002
• Minor Utility Strike During Horizontal Boring
  Operations
• Sub Personnel Drilled Anchor Bolts in Concrete
  Encased Electrical Duct Bank
• U4A Beam Line User Received Electrical Shock _at_
  NSLS
• 2003
• Forklift Load Strikes Overhead Lines
• Employee Received an Electric Shock to Hand
  During Magnet Operations _at_ Physics
• Communication Cable Struck During Excavation
• 2004
• Electrical Utility (Encased in Concrete Floor)
  Conduit Strike
• Potential Fire Hazard (electrical arc) in AGS
  Cable Tray
• Worker Experiences Electric Shock During Beam
  Line Water Hose Replacement _at_ NSLS
• 2005
• Unexpected Discovery of Electrical Hazardous
  Energy Source _at_ Magnet Division
• Energized Wire Discovered During RF Power Amp
  Repair _at_ C-AD
• Unauthorized Modification to Power Cord Prongs
• 2006
• 400 Amp Electrical Switch Failure (arc flash) _at_
  C-AD
• Exposed Electrical Terminals in Legacy Installed
  Light Timer _at_ Medical

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7 BNL Electrical Workers Near Misses 2002-2006

• 2002
• U4A Beam Line User Received Electrical Shock _at_
  NSLS
• 2003
• Employee Received an Electric Shock to Hand
  During Magnet Operations _at_ Physics
• 2004
• Worker Experiences Electric Shock During Beam
  Line Water Hose Replacement _at_ NSLS
• 2005
• Unexpected Discovery of Electrical Hazardous
  Energy Source _at_ Magnet Division
• Energized Wire Discovered During RF Power Amp
  Repair _at_ C-AD
• 2006
• 400 Amp Electrical Switch Failure (arc flash) _at_
  C-AD
• Unexpected Energized Cord Cut _at_ NSLS

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4 BNL Electrical Intrusion Near Misses 2002-2006

• 2002
• Minor Utility Strike During Horizontal Boring
  Operations
• Sub Personnel Drilled Anchor Bolts in Concrete
  Encased Electrical Duct Bank
• 2003
• Communication Cable Struck During Excavation
• 2004
• Electrical Utility (Encased in Concrete Floor)
  Conduit Strike

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1 BNL Vehicle Near Misses 2002-2006

• 2003
• Forklift Load Strikes Overhead Lines

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5 BNL Non-Electrical Workers
Near Misses 2002-2006

• 2004
• Potential Fire Hazard (electrical arc) in AGS
  Cable Tray
• 2005
• Unauthorized Modification to Power Cord Prongs
• 2006
• Exposed Electrical Terminals in Legacy Installed
  Light Timer _at_ Medical
• Energized Conductor Discovered in Cut Conduit _at_
  Chemistry
• Painter's spackling knife contacts abandoned live
  electrical wiring

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17 BNL Electrical Safety Occurrences2002-2006
(Activity Category)
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17 BNL Electrical Safety Occurrences2002-2006
(Cause Codes)

• TOP 6 CAUSES
• Defective or Failed Part
• Individual justified action by focusing on biased
  evidence
• Inadequate work package preparation
• Incomplete / situation not covered
• Lack of written communication
• Comm. between work groups LTA

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BNL Electrical Safety Occurrences
(2002-2006)Lessons Learned Statements

• A routine task can easily become a hazard if the
  required procedure is not followed or if
  attention to detail is not applied.
• Do not assume that the hazards in your work area
  are always at your eye/foot level. Be aware of
  ALL your surroundings.
• Reliance on word of mouth should not have removed
  the requirements to initiate adequate hazard
  reviews.
• Construction activities should require written
  communication and/or verification of work
  completion.
• A complete review of all systems should be
  conducted prior to any operations, even if the
  manufacturer's representative has carried out
  installation.
• All electrical equipment connected to line
  voltage must be bonded to ground. It cannot be
  assumed that even very heavy equipment sitting on
  stone is adequately connected to ground.

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BNL Electrical Safety Occurrences
(2002-2006)Lessons Learned Statements

• Heat tapes used in cryogenic applications in
  order to prevent icing must be capable of
  functioning in wet environments even when it is
  not anticipated that ice will build up.
• A safety review prior to start of work is needed
  whenever significant changes to approved
  electrical configurations are made.
• In a user facility, communication of key ESH
  messages should be carefully and consistently
  expressed to ensure that key requirements have
  been understood and accepted by visiting
  scientists.
• Ensure that all beamline and facility equipment
  with significant hazards has clear ownership and
  a responsible person.
• Do not assign work as "skill of the worker" on
  equipment with electrical or other energy sources
  that you are unfamiliar with.
• Do not alter the configuration of equipment or
  components unless you are authorized to make
  changes and are knowledgeable of the hazards
  associated with the equipment.

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BNL Electrical Safety Occurrences
(2002-2006)Lessons Learned Statements

• Project managers are responsible to ensure that
  they comply with all applicable procedures for
  the work that they perform or execute. It is
  imperative that the Project Manager review all
  project requirements with the contractor to
  ensure thorough job knowledge and operating
  conditions are known.
• The process of identifying concealed utilities
  embedded in concrete is an inherently challenging
  and imprecise process that, even when carried out
  in accordance with established procedures and
  utilizing the latest detection equipment, does
  not guarantee the utility can be precisely
  located. Personnel must recognize the uncertainty
  involved and assure that all relevant information
  about the area in question has been communicated
  and that all reasonable measures have been taken
  to protect the safety of workers and facilities
  prior to authorizing the start of work in the
  area. Due to this uncertainty, embedded utilities
  should be avoided in all new designs and
  de-energized whenever possible if penetrations
  are required during construction.

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Electrical R ORPS Reports

• 10 Electrical R Reports issued across complex
• Hanford Site (3)
• Yucca Mountain
• Idaho National Lab (2)
• Sandia National Lab
• Los Alamos National Lab
• Savannah River Site
• Rocky Flats Env. Technology Site
• Note On 2/28/05 BNL ORPS Categorizers voted
  that an R Report concerning utility strikes was
  not warranted.

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Electrical ORPS Reports

• 17 BNL Report CAUSES
• Defective or Failed Part
• Individual justified action by focusing on biased
  evidence
• Incomplete / situation not covered
• Lack of written communication
• Inadequate work package preparation
• Comm. between work groups LTA

• 10 R Report CAUSES
• Check of work was LTA
• Management policy guidance / expectations not
  well-defined, understood or enforced
• Work planning not coordinated with all
  departments involved in task
• Inadequate work package preparation
• Comm. between work groups LTA

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DOE Electrical Safety Special Report
2004-02Suggested Measures to Prevent Electrical
Work Occurrences

• Walk down the work site to (1) identify equipment
  to be worked on, (2) ensure that equipment to be
  isolated is clearly marked, (3) verify or modify
  drawings to reflect as-built conditions, and (4)
  identify additional hazards or other safety
  issues.
• For decommissioning work, re-evaluate electrical
  hazards as systems and equipment are dismantled
  and isolations are removed.
• Ensure that lockout/tagout procedures or work
  instructions include a zero-energy check to
  confirm the effectiveness of the lockout/tagout
  installation. Always perform a zero-energy check
  on the circuit to be worked, as well as on other
  nearby circuits and terminals. Perform these
  checks any time new areas or equipment are
  accessed.
• Upon completion of wiring work, check for proper
  voltages, phasing, and grounding.
• Use lockout/tagout processes if there is a
  possibility that work may be performed in close
  proximity to energized electrical conductors.
• Ensure that lockout/tagout procedures or work
  instructions include independent verification
  that the lockout/tagout has been correctly
  performed.

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DOE Electrical Safety Special Report
2004-02Suggested Measures to Prevent Electrical
Work Occurrences

• Ensure that purchased electrical components and
  equipment are acceptance-tested before they are
  put into service.
• Work on energized circuits should be performed
  only after obtaining special approvals and
  developing job-specific safety controls.
• Always use electrical-rated PPE (e.g., insulated
  gloves and boots, ground-fault circuit
  interrupters, double-insulated tools, and rubber
  mats) when working on energized electrical
  circuits and equipment.
• Stop work if an unanticipated electrical hazard
  or condition is encountered and seek appropriate
  assistance.

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DOE Electrical Safety Special Report
2004-02Suggested Measures to Prevent Electrical
Intrusion Occurrences

• Drill pilot holes and penetrate no deeper than is
  required for the job.
• Check drill holes frequently for obstructive
  material, such as wire fragments or rebar.
• Always wear personal PPE.
• Clearly mark components that are to be removed
  and establish boundaries and hold points for zero
  energy verification when performing demolition
  work.
• Conduct source checks for energy near the work,
  and not just at known energy sources.
• Exercise stop work authority if unanticipated
  conditions are encountered.
• Use appropriate PPE equipment that has proper
  electrical ratings.
• Standardize methods for identification and
  location of concealed or buried electrical
  utilities.

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DOE Electrical Safety Special Report
2004-02Suggested Measures to Prevent Electrical
Intrusion Occurrences

• MO contractors should share information such as
  locator data, drawings, and permit information
  with subcontractors performing the work.
• Analyze the specific work activity and do not
  just base hazards controls on established
  standards and work practices.
• Perform excavation and penetration work in a
  timely manner following surveys and marking of
  locations. Markings can deteriorate over time,
  and conditions can change.
• Employ utility locator services or use the latest
  survey technology available.
• Hand-excavate in close proximity to the expected
  location of the utility rather than using
  excavation equipment.
• Re-evaluate hazards analysis processes and
  associated controls for excavation and electrical
  penetration-type work.
• Place marking tape or electronic markers above
  newly installed utilities or excavated utilities
  to aid in future identification.

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DOE Electrical Safety Special Report
2004-02Suggested Measures to Prevent
Vehicle/Electrical Occurrences

• Job hazard analyses for tasks involving vehicles
  need to include all work areas and travel routes
  to identify overhead electrical hazards and to
  address appropriate requirements for vehicle
  clearances and an adequate number of spotters.
• Job hazard analyses should also consider the
  possibility of changed vehicle profiles and load
  configurations, such as raised truck beds, the
  shifting of masts and booms, and the increased
  heights of vehicles after unloading.
• Spotters assigned to transports need to be
  dedicated for the whole job, including exiting.
• Drivers must be trained to stay in communication
  with spotters and to be aware of the effect of
  changed vehicle and load configurations on
  clearances.
• Guy wires, utility poles and overhead lines need
  to be marked if not clearly visible to drivers
  and spotters.

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DOE Special Operations ReportElectrical Safety,
August 2006

• 2005 Secretarys Directive
• Demonstrate adequate performance expectations
• Demonstrate accountability for improved
  electrical safety
• More electrical events in 2005 than 2004
• Significant increase in LOTO events and shocks
• Significant concern regarding the safe
  performance of electrical work
• 2006 All electrical safety improvement
  activities under EFCOG
• Electrical Safety Improvement Project Plan
• Actions implemented by end of CY 2006

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DOE Special Operations ReportRecurring Process
Area Issues

• Inadequate Work Planning and Hazards
  Identification
• Failure to
• Understand the scope of work
• Adequately review drawings and walk down the job
• Consult with SMEs
• Identify adequate barriers
• Prescribe appropriate PPE
• Stop work when unanticipated conditions are
  encountered
• Hazardous Electrical Energy Control
• Failure to
• Follow LOTO procedures
• Perform independent verification
• Electrical Safety Compliance
• Failure to
• Perform zero-energy verification
• Wear properly rated PPE
• To use electrically rated tools
• Have sufficient justification for working hot

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DOE Mandated Response

• DOE provided Lines of Inquiry to assess
  electrical safety program
• Electrical Work Planning Process
• LOTO Process
• Zero-Energy Check and Energized Work Process
• Specifically looking at
• Procedures
• Training
• Implementation
• Verification

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Defining a World-Class Electrical Safety
Program

• Adapted from Breakthrough Safety Management -
  by S. Smith - 06/08/2004
• http//www.occupationalhazards.com/safety_zones/47
  /article.php?id11919
• Electrical events have been eliminated.
• Electrical safety is perceived by management as a
  competitive advantage.
• Consistent electrical safety processes are
  encouraged and supported by management.
• Electrical safety processes are externally
  verified through outside audits.
• Benchmarking against other organizations is
  promoted.
• Electrical safety accomplishments are
  acknowledged by outside organizations.
• Electrical safety achievement is sustainable.
• Other organizations seek out BNL to mentor them
  in electrical safety.

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BNLs World-Class Electrical Safety Program

• Why Not Us? Why Not Now?

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Beyond BNL Electrical Safety Programs

• Hanford
• U.S. Navy
• Strategic Petroleum Reserve
• Bayer Pharmaceutical
• Savannah River Site
• Princeton Plasma Physics Laboratory

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Beyond BNL Hanford

• Contact Victor Edens, [phone]
• Establish a centralized work control and planning
  center to control work on, or adjacent to,
  operating systems and hazardous energy sources.
  (Construction Utilities Group, CUG)
• Life Critical Safety Procedures approved by CUG
• Incorporate comprehension tests and practical
  evaluations into training for LO/TO, Confined
  Space, Hazardous Work Permit, Zero Energy Checks,
  and Excavations.
• The frequency in which an individual implements a
  given work control program should also be a
  factor in determining how often refresher
  training is required.
• Need to Test/verify Supervisor's ability to
  identify hazards on a regular basis. (i.e.
  Evaluate a supervisor's ability to identify
  hazards by observation during periodic
  participation in an area safety walk exercises
  involving photo review to identify hazards and
  other training means).
• Implement STARRT Card, addresses ISM 5 core
  functions

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Beyond BNL U.S. Navy

• Contact Chief Mackey, [phone]
• USS Wyoming (Gold) was recognized as the best
  Electrical Safety Program
• http//www.safetycenter.navy.mil/default.htm

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Beyond BNL Strategic Petroleum Reserve

• Contact Will Woods (DOE), [phone]
• Close Call Program
• Human Factors Program
• Hired contractor to complete arc flash
  calculations

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Beyond BNL Bayer Pharmaceutical

• Contact Frank Caslaina, [phone]
• Electrical workers wear FR clothing at all times
• After deeneergizes gt 480 v load side is grounded
  prior to work

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Beyond BNL - Savannah River Site

• Contact Jackie Mcalhaney, [phone]
• Electrical Site-wide stand down Summer of 05
• LOTO, DD, Equip. Abandonment, Drilling, and
  Excavation
• Electrical Safety Awareness Week (Raised
  Awareness)
• Tailored presentations to Admin., Field, and
  Electrical Workers
• Facility walk downs (1200 findings, most minor)
• Exposed conductors
• Electrical Safety Express Publication written
  by SMEs
• Referenced during tool box meetings
• Vacuum type Technology, Location of buried
  utilities (No hand digging)
• Mounted on trailer uses air/water/vacuum
• Contact Jack Goldenburg, [phone]
• Proximity Voltage Detector
• Tech DVA 30 (detects voltage and current)

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Beyond BNL - Savannah River Site

• Signed Work Expectation Form, 100 voltage checks
• All LOTOs reviewed by Engineer prior to start of
  work
• Formal Analysis Program Software Program
• Outputs hazard analysis tree based on site
  requirements
• Stop Work out, Time Out in
• Now workers to stop
• Encouraged to take time out
• Reinforced
• Annual Training on Energized Work Procedure
• 1st time Live Instructor

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Beyond BNL - Princeton Plasma Physics
Laboratory

• Contact John Lacernere, [phone]
• 4 Tier Safety Program (Initially provided by
  Live Instructor)
• 3 Year Re-training Cycle or as Needed
• Introductory training
• Basic electrical training
• Electrical utility training (EUT)
• High voltage maint. training (Admin by PSEG)
• Bus work is deenergized when racking breakers or
  done remotely
• Bus work is deenergized when racking MCC buckets
• Nothing requires working hot except
  troubleshooting
• CONVENIENCE IS NEVER TO OVERRIDE SAFETY
• Contractor Work
• Qualified to work electrically by PPPL beyond EUT
• Heavily supervised by PPPL, at least initially

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Beyond BNL - Princeton Plasma Physics
Laboratory

• Raised awareness of arc flash issue across site
• Folks did not fully appreciate potential danger
• Resulted in fewer people operating
  switches/breakers

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The Path Forward

• As directed by the Deputy Director of Operations
• The results of this evaluation/search will be
  presented to the ALD for ESHQ, the Safety and
  Health Services Manager, and the Laboratorys
  Electrical Safety Committee for them to assess
  the applicability to BNL.