At approximately 8:00 a.m. on June 27, 2017, an employee was working as a lineman on a crew for a power transmission company tasked with removing a part from a distribution bus at a distribution substation. A crew from the distribution service operator was in the process of isolating the distribution lines that were terminated at the substation. The two crews did not properly coordinate their de-energization activities and the transmission crew mistakenly believed the distribution equipment to be properly isolated from the system. The crew did not properly test and ground the equipment prior to starting work. While working on the equipment the employee came into contact with an energized conductor and received electric shock. The employee was hospitalized and treated for electric shock.
No communication or coordination between crews.
Crews did not properly test and ground equipment.
What Can We Learn?
By performing a Critical Step Check, an action identified before the work begins that must be performed correctly to avoid adverse consequences or cause irreversible harm, would have helped the crew properly test and ground equipment before work began.
By having a Questioning Attitude, the transmission crew would have questioned if there was coordination between the two crews to complete the job safely.
The two crews experienced Overconfidence in that they both overestimated their confidence in communicating and coordinating with each other.
Time Pressure was a factor in the crews rushing to get the job done vs. taking the time to ensure they were working in a safe environment.
Ask the Right Questions