Use Human Performance Tools to Prevent Lockout/Tagout Errors
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Type:  Lessons Learned

Publisher:  CH2MHill Plateau Remediation Company (Richland, WA - Hanford Site), Richland, WA - Hanford Site (CHPRC)

Published As:  Public

Date: 

Topics:  Electrical, Operations, Work Management/Planning, Hazardous Energy Control

During a maintenance work activity that followed the installation of a lockout/tagout, an electrical spark was observed while work was in progress. There were no injuries. The work team was unaware of an unlabeled secondary power source that was encountered during the work evolution. Effective use of human performance tools and enhanced equipment labeling could have prevented this event.

Lessons Learned: Consistent and effective use of human performance tools may prevent error during work evolutions, including those involving lockout/tagout. These tools include maintaining a questioning attitude, stopping when unsure, conducting a thorough pre-job briefing. Additionally, the effective use of equipment labeling can alert facility personnel to component-specific hazards. When an event occurs, immediate actions should be taken to place equipment in a safe configuration ONLY in the event that urgent action is necessary to avoid imminent and serious consequences.

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