Failure to Identify Secondary Power Source Leads to Worker Exposure to 480V
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Type:  Lessons Learned

Publisher:  Mission Support Alliance, Hanford Site

Published As:  Public

Date: 

Topics:  Electrical, Operations, Maintenance, Work Management/Planning

A Controlling Organization Administrator and an Authorized Worker used an Eight Criteria Checklist to Lockout a HVAC heating unit that had a dual energy source. The COA and the Authorized Worker did not test the electrical components that were located inside an enclosed cabinet and therefore did not verify that the equipment had a single energy source. This lead to the worker being exposed to 480 volt power and could have resulted in serious injury to the worker, up to and including death.

Lessons Learned: When electrical components are located or contained in an enclosed work space, circuit confirmation must be performed within that work space. Had the team performed an adequate verification of the circuit, including the work location, and isolation points, the second power source would have been discovered and this event would not have occurred.

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