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From: CHAS membership <membership**At_Symbol_Here**DCHAS.ORG>
Subject: [DCHAS-L] Lessons Learned Resulting from Dyno Drive Cabinet Opened Prior to Lock/Tag/Verify
Date: Thu, 4 Nov 2021 08:55:22 -0400
Reply-To: ACS Division of Chemical Health and Safety <DCHAS-L**At_Symbol_Here**Princeton.EDU>
Message-ID: C8082FA6-1CA7-4DDF-9271-9890B5F7B93A**At_Symbol_Here**dchas.org
This Lessons Learned from Oak Ridge National Lab is a situation that I have seen occur in the complex research facility setting - the scope of repair work can change as the work goes forward and identifying when a new risk assessment is appropriate becomes a challenge. I have seen many situations where trades people on the trail of a problem enter areas with unusual hazards. This is a key challenge that both lab scientists and trades managers should be aware of.
- Ralph
Lessons Learned 2021-UTB-ORNL-0030 Lessons Learned Resulting from Dyno Drive Cabinet Opened Prior to Lock/Tag/Verify
Topics: Change in Conditions, Electrical, Lock/Tag/Verify
Event Originator: Jarrad Stump
OE Document Number: 15795
Statement: When conditions in the planned scope of work changes (such as with troubleshooting) that results in work being performed outside of the scope of the procurement document (purchase order) that did not receive an ES&H review or activity hazard analysis, additional hazard evaluation needs to be performed.
Discussion: On January 28, 2021, UT-Battelle (UT-B) subcontractor service technicians were performing troubleshooting activities on an electric dynamometer drive system at the ORNL National Transportation Research Center, Building 2360HVC. These activities were related to the vendor installation of the new dynamometer drive systems to support engine research in the facility.
The scope of work on the purchase order (PO) for the procurement and commissioning of the dynamometer system was limited to non-hazardous tasks. That PO was not marked for an ORNL ES&H review as no electrical work was expected during commissioning. No additional POs were entered for the follow up visits to troubleshoot and replace components because those visits were covered under the commissioning task. The installation of the dynamometer system was completed under a tenant improvement request using a separate subcontractor that was managed by the building landlord.
When the dynamometer commissioning experienced a technical issue, the subcontractors started to troubleshoot the equipment without recognition that this was a change in the scope of the work. The PO was not re-evaluated for any new hazards associated with troubleshooting (physical work beyond basic commissioning of the unit/system). The PO should have been modified to include an ES&H review and an activity hazard analysis (AHA) for any work done near energized circuits or circuits under the protection of Lock/Tag/Verify (LTV).
During these troubleshooting activities, the subcontractors opened the 480-volt dynamometer drive cabinet to access a communication cable port. This activity was outside the authorized scope of work. Opening the dynamometer drive cabinet door de-energizes the load side power to the 480-volt disconnect at the bottom of the cabinet, however the 480-volt line side power was still energized and not suitably guarded. The dynamometer drive cabinet was not protected by an issued LTV.
That same day at approximately 8:45 AM, the Division Electrical Safety Officer (DESO) supporting the Buildings and Transportation Science Division, arrived to the mezzanine area of building 2360HVC to assist with the third LTV for this subcontractor. When the DESO arrived at the area, the DESO noticed that the dyno drive cabinet door was being closed by one of the subcontractors. The DESO reminded the contractors that they are not allowed to operate any breakers or disconnects or to open or access the cabinets unless they are on the permit and overlocked with a personal lock. This was discussed in a pre-job briefing for first LTV earlier that week. The DESO proceeded to lock out the 480V feed that was coming into the dyno drive cabinet. The DESO notified the Technical Project Officer (TPO) delegate and their management about the event. The DESO then proceeded to ask the contractors to suspend work. The panel was placed in a safe condition and management was then notified. No!
injury or shock to personnel occurred, nor any damage to the equipment due to this event.
Analysis:
?’ Change in condition resulted in work performed outside the scope of work of the purchase order (PO). The scope of work on the PO for the procurement and commissioning of the dynamometer system was limited to non-hazardous tasks. That PO was not marked for an ORNL ES&H review as no electrical work was expected during commissioning. A change in condition resulted in the contractors conducting troubleshooting activities which created hazards not previously assessed.
?’ Being unfamiliar with ORNL processes, the subcontractors did not realize working within the electrical cabinet was outside of the scope of the subcontract and thought that troubleshooting and checking functionality of the equipment was within the scope of the commissioning process. Therefore, the subcontractors did not follow the direction of the DESO presented to them during the initial pre-job briefing.
Lessons Learned:
?’ No matter the task, understanding work control responsibilities, delegation of authority, proper planning, and effective communication are requirements for safe operations.
?’ Work activities should be performed within the defined scope of work. A change in conditions that results in a new or expanded scope of work must be evaluated for new/additional hazards. For subcontracted work the PO should be updated (or a new PO issued) to reflect the new scope of work and receive the proper reviews.
?’ It is important to communicate ORNL??s expectations and procedures to subcontractors.
?’ Don??t assume everyone involved has equal working knowledge of the hazards and controls.
Everyone involved in the job should be aware of the hazards, regardless of who is performing the actual work.
Safe Conduct of Research (ScoR): The SCoR principles should be considered when planning/proposing work, during RSS development (hazard identification and control), and at all times when conducting or performing work. During the course of the subject event investigation and the review of the associated PO, it was evident that many of the SCoR principals were not considered as work was performed outside the defined scope of work.
The SCoR principles are as follows:
?’ Everyone is personally responsible for ensuring safe operations.
?’ Leaders value the safety legacy they create in their discipline
?’ Staff raise safety concerns because trust permeates the organization
?’ Cutting-edge science requires cutting-edge safety
?’ A questioning attitude is cultivated
?’ Learning never stops
?’ Hazards are identified and evaluated for every task, every time
?’ A healthy respect is maintained for what can go wrong
Recommended Action:
Multiple corrective actions will be completed in accordance with the actions approved under formalized corrective action plan.
References:
?’ Critique Report
?’ ORPS Report SC-OSO--ORNL-X10LEASED-2021-0001 FINAL, Dyno Drive Cabinet
Opened Prior to Lock/Tag/Verify (ACTS 0.41099)
?’ NTS Report NTS-SC-OSO-UTB-X10BOPLANT-2021-0010202 (ACTS 0.41099)
Contact: Gerald Barth
ESTD Operations Support and Division Electrical Safety Officer
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