Two Electricians were assigned to disconnect the motor leads to the 23B Circulating Water (4kV) Motor. After removing the insulation from two of the motor connections, they questioned if they were on the correct motor because the number of conductors did not match the 23B Circulating Water Motor that they had worked on the previous day. After reviewing their work order, they realized they were on the wrong motor.They had begun to disconnect 23A Circulating Water Motor.The electricians immediately stopped work, isolated the area and contacted their supervision.
A 2 Minute Drill had not been performed prior to starting work on this component. This process asks specific questions regarding component verification.
What Can We Learn?
A Self Check and Questioning Attitude would have lead workers to ask the question, “Am I on the right component?”
A Peer Check could have identified they were on the wrong component before they performed step one of the task.
The lack of Human Performance Tool usage is a sign of Overconfidence by the workers involved.
The Physical location of both components were in close proximity of one another. (Physical Environment)
Ask the Right Questions