REG NASA-LLIS-0461-1993 Lessons Learned - H-1 Test Stand Construction project.pdf

1、Lessons Learned Entry: 0461Lesson Info:a71 Lesson Number: 0461a71 Lesson Date: 1993-09-21a71 Submitting Organization: SSCa71 Submitted by: Mike RewisDescription of Driving Event: On 09 September 1993, at approximately 1853 hours, the construction safety office was notified of a mishap at the H-1 Tes

2、t Stand Construction project at the intersection of lateral access and KDT roads, SSC. The field engineer informed ASRM Construction Safety that a wheel mounted crane, operated by a construction contractor employee, had come into close proximity of the bottom phase of the 13. 8KV electrical service

3、line crossing lateral access road west of kneel down transporter (KDT) road. The field engineer reported visible electrical arcing between the crane boom and electrical phase for approximately 10-15 seconds. The field engineer stated the operator appeared to be uninjured. Construction safety asked t

4、he field engineer to secure the mishap scene and traveled to the job sit to meet with the field engineer, the operator, and the project superintendent to investigate.At approximately 1840, the crane was moved from the motor conditioning building steel frame and was being staged for pick up by the Eq

5、uipment Rental Co. the following morning. The operator asked the project superintendent where to stage the crane and was directed, by the Project Superintendent, to the intersection of KDT and lateral access roads. The operator drove the crane to the staging area with the boom elevated approximately

6、 30-35 degrees. In his original statement, the operator stated he approached the staging area he saw and was cognizant of the location of the boom tip referent to the electrical service line. In a follow up interview and statement, the operator reported that he saw the power line from a distance of

7、approximately 20 feet. His attention was then given to an Ensley track hoe parked to his front (under the power line) and he never looked back at the power line until the arcing began. The operator stated and reaffirmed he stopped the crane with the boom tip approximately 1-2 feet from the line and

8、set the parking brake. The operator reported and reaffirmed the crane rolled an additional 12-18 inches after the parking brake was set. When the crane stopped the electrical arcing began. The operator immediately exited the crane cab and dismounted the crane by grabbing the metal handrail on the do

9、or of the cab and jumping 6 feet 3 inches to the ground out and away from the crane cab. The operator reported being shocked when he grabbed the handrail but stated he was uninjured as a result.Lesson(s) Learned: Provided by IHSNot for ResaleNo reproduction or networking permitted without license fr

10、om IHS-,-,-1. Operator failed to maintain minimum clearance by traveling the crane, with the boom tip elevated at approximately 30-35 degrees, to within 3-4 inches of an energized 13. 8KV electrical power line. A minimum clearance of 10 feet must be maintained when cranes are operated proximate to e

11、nergized electrical distribution and transmission lines rated 50KV or below. 29 CFR 1926. 550(a)(15)(i).2. Operator failed to designate a qualified signal person to observe clearance of the equipment and give timely warning where it was difficult for the operator to maintain the required clearance b

12、y visual means. 29 CFR 1926. 550(a)(15)(iv).3. Employer does not have formal training and certification for crane operators. Operator has not received formal crane operator certification training from the employer. ANSI B30. 5. The employer did not require the operator to pass a written or oral exam

13、ination, practical operating examination, or to furnish satisfactory evidence of training and experience.Recommendation(s): 1. Employees should not operate cranes or other heavy equipment until formally trained and certified by the employer on the safe operation of specific equipment. As well, high

14、visibility markers should be installed in order to provide a higher probability that an operators attention will be drawn to the power line prior to encroaching into the danger zone.2. Employees should not operate cranes or other heavy equipment until formally trained and certified by the employer o

15、n the safe operation of specific equipment.3. Employers should develop and implement a crane operator training and certification program in accordance with ANSI B30. 5. Additionally, employers should provide a submittal to SSC ASRM Safety identifying “Designated operators“ for lifting equipment, inc

16、luding personnel aerial lifts.Evidence of Recurrence Control Effectiveness: Have experienced no similar mishap since 09/09/93.Documents Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 EnergyProvided by IHSNot for ResaleNo reproduction or networking permitted without li

17、cense from IHS-,-,-a71 Lifting Devicesa71 Safety & Mission AssuranceAdditional Info: Approval Info: a71 Approval Date: 1996-10-17a71 Approval Name: Mike Rewisa71 Approval Organization: QA00a71 Approval Phone Number: 601-688-2663Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-