Improper Grounding (KV 147)

 

What Happened?

Four electricians were injured while installing grounding cables inside a load control center. One electrician inadvertently placed the grounding cable connecting rod on an energized stab.

Contributing Factors

There were no known contributing factors.

What Can We Learn?

Tools

Written instruction (Procedures) would have ensured the grounds were installed properly.

Questioning Attitude used consistently would have caused workers to question PPE requirements and error prevention techniques.

A Peer Check could have prevented the electrician from installing the ground on the energized stab.

Traps

These workers, with limited experience and training, received Vague Guidance for performing this task.

This task was being performed at a higher risk due to energized equipment in close proximity. (Physical Environment)

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?