A death results when safety procedures are ignored

Although a presentation on the post-mortem analysis of an incident resulting in a worker death is somber, it’s also a learning event and reminder that safety must always be reinforced, even if, as in this case, you’ve performed a task a hundred times before. Users were reminded of this at the Combined Cycle Users Group’s (CCUG) 2017 Annual Conference, held in Phoenix the last week of August

In the case described (at a hydro facility), the task was to clean a de-energized 13.8-kV bus. A veteran worker, who had performed this task 26 times before, was left alone as his team member left to retrieve an item they had forgotten for the job. He returned to find the veteran co-worker “energized” and lying on the ground.

Inexplicably, what happened was that the two of them had noticed a flat washer on the floor. While the veteran was alone, he wanted to “fix the problem” and put the washer where it needed to be. In doing so, according to the post-mortem, he violated multiple safety rules. He rolled stairs over, unlocked a locking mechanism (apparently every employee has a master lock key), removed rods, and opened the door to an energized 13.8-kV cubicle above the one they were assigned to.

He noticed a broken bolt, found a flashlight in the back of the top cabinet to shine on the bolt. They found his hard hat in the back of that cabinet. The top of his head apparently came in contact with the energized bus. The veteran proceeded on his own even though the two of them “had the conversation” that the top cabinet was energized. Not only should he not have worked alone, no out-of-scope work should have been done unless workers stop to discuss it.

Organizationally, there wasn’t much to do, other than reinforce existing processes and procedures. The owner/operator did eliminate master locks on this type of equipment and began a program to reward those who bring problems back for collective discussion, rather than solve them alone. However, nothing is going to stop someone from lapses of judgment or a determination to solve a problem on their own while no one is looking.

One audience member responded that energized gear “keeps him up at night.” Sometimes equipment just malfunctions and you can’t blame the person, and sometimes the person makes a mistake—especially when tired. Another attendee reported that they run safety drills at his plant unannounced weekly, and then evaluate responses and performance afterwards.

Perhaps the overarching lesson here is complacency can kill.

Others asked, “What constitutes emergent work?” and how to you handle it. Staff needs to be empowered to stop work to question and be certain, and be supported by management for doing so. One tool to assist in performing work safely that was mentioned may be the latest models of cameras, which can be used to troubleshoot problem areas and document tasks.

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