1、Lessons Learned Entry: 1365Lesson Info:a71 Lesson Number: 1365a71 Lesson Date: 2003-09-08a71 Submitting Organization: KSCa71 Submitted by: Robert PrestonSubject: Lock out/Tag out Procedure Not Followed Abstract: A mechanical technician came into contact with an energized electrical circuit at the LC
2、-39, Pad A Oxidizer Storage Area. A control cabinet had been removed and the circuit breaker feeding the bare conductors had been locked out in the electrical switchboard. Another contractor was modifying the electrical distribution system. The LOTO device was improperly removed and the circuit was
3、later re-energized.Description of Driving Event: On July 10, 2003, a mechanical technician came into contact with an energized electrical circuit at the LC-39, Pad A Oxidizer Storage Area. A control cabinet had been removed and the circuit breaker feeding the bare conductors had been locked out in t
4、he electrical switchboard. Another contractor was modifying the electrical distribution system. The LOTO device was improperly removed and the circuit was later re-energized.Lesson(s) Learned: 1. Hazardous situations can be created if LOTO devices are improperly removed.2. 3. During construction, it
5、 is critical to understand the proper placement of LOTO devices.4. Hazardous situations can be created if bare conductors are not properly secured.5. During electrical system modification, it is critical to involve all affected users.6. After electrical system modification, it is critical for affect
6、ed users to revalidate their systems.Recommendation(s): Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-1. Do not improperly remove LOTO devices.2. 3. Understand system configuration to ensure proper placement of LOTO devices.4. Adequately guard or g
7、round exposed conductors when working on electrical systems, even if the circuit has been de-energized or LOTO has been applied.5. Ensure all users affected by an electrical system modification are aware of configuration changes.6. Ensure all affected users revalidate their systems after electrical
8、system modifications are complete.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: NPG8715.3 Chapter 6 Paragraph 6.5Mission Directorate(s): N/AAdditional Key Phrase(s): a71 Accident Investigationa71 Configuration Managementa71 Facilitiesa71 Ground Equipmenta71 Human Fact
9、orsa71 Industrial Operationsa71 Personal Protective Equipmenta71 Safety & Mission AssuranceAdditional Info: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 2003-09-29a71 Approval Name: Gena Bakera71 Approval Organization: KSCa71 Approval Phone Number: 321-867-4261Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
