Electrical Near Miss (KV 132)

 

What Happened?

A crew of Electricians were working under a clearance tag to relocate conduit. The work required removal of conductors from two conduits and then re-routing conduits several feet away to prevent interfering with the new control box. 

The Work Order Instructions required verifying all conductors were de-energized and then de-terminating all conductors using a lifted lead sheet.  However, discussions between the 2 electricians and their supervisor during the pre-job brief lead to a decision to deviate from the work package.  This plan required cutting the conductors in the junction box during which the electrician noticed a faint spark. Subsequent investigation revealed an additional circuit breaker that should have been tagged but was missed during job planning. Fortunately, there was no injury to personnel.

Contributing Factors

Work group deviated from the work plan.

Protective tagging plan was inadequate.

Workers failed to verify all conductors were de-energized before performing this task.

What Can We Learn?

Tools

Effectively following Procedures pertaining to Electrical Safe Work Practices would have mitigated the risks associated with this near miss.

A Self Check or Peer Check would have encouraged the crew members to perform a zero energy test, further addressing potential negative outcomes.

Traps

The entire crew displayed Overconfidence by not following standard Electrical Safe Work Practices.

The crew imposed Peer Pressure on one another to deviate from the established work package, and perform steps in a different order than planned.

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?