HPI Opportunities from LOTO Activities Review

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Type:  Lessons Learned

Publisher:  Consolidated Nuclear Security - CNS - Bechtel, Leidos, Orbital ATK SOC Booz Allen Hamilton (Various Locations), Oak Ridge, TN (Consolidated Nuclear Security - CNS)

Published As:  Public


Topics:  Electrical, Operations, Radiation Protection, Oversight

After a series of LOTO events occurred across different work groups within the Y-12 Infrastructure Management organization, a HPI Investigation was performed to evaluate the human errors and look for improvement opportunities to avoid similar future events. The investigation encompassed three events where: a suspected energized circuit was encountered while cutting a conduit with a power saw; a LOTO activity involving valve alignment that was not adequately performed and confirmed; an unplanned power outage occurred during a high-voltage distribution switching activity. In each circumstance, personnel actively engaged did not realize a decision error had occurred and failed to pause or stop work before proceeding.

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