1、Lessons Learned Entry: 1368Lesson Info:a71 Lesson Number: 1368a71 Lesson Date: 2002-08-29a71 Submitting Organization: JSCa71 Submitted by: Ronald A. MontagueSubject: Implementation and Verification of Lockout/Tagout Procedures Abstract: An employee received an electrical injury after coming in conta
2、ct with an energized electrical circuit while wiring a relocated emergency generator; the employee subsequently died of the injury. The subsequent investigation revealed three central themes involved in the mishap: 1. Implementation and Verification of Lockout / Tagout Procedures (the subject of thi
3、s lesson),2. Accurate Drawings of Facility Systems as a Prerequisite to Project Implementation, and3. Demand and Ensure High-Quality Safety Performance from all Contractors.Each theme is published as a separate lesson. (A fourth lesson underscores the successful implementation of the preliminary inv
4、estigation, which was critical to performing a successful, formal mishap investigation.) Description of Driving Event: An employee received an electrical injury after coming in contact with an energized electrical circuit while wiring a relocated emergency generator; the employee subsequently died o
5、f the injury.Finding A: Employees must personally verify, prior to starting work on a potentially energized system, that the system is de-energized and their personal lock and tag are in place. Do not take the word of a co-worker or supervisor. If the employee leaves the work site for any reason, re
6、-verify the system is still de-energized before resuming work. The following evidence supports this finding: 1. At the beginning of the day, the foreman improperly checked the voltage at the junction box where the mishap occurred. The improper check was a result of using a painted surface as a groun
7、d reference.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-2. After this initial check by the foreman, the circuit was not re-checked by any of the electricians working on the generator circuits. All the electricians working at the site assumed the
8、circuits were de-energized.3. The contractor did not pursue understanding of the circuits or request NASA assistance in identifying circuit breakers that would de-energize circuits.4. The NASA-delegated safety and quality inspectors on the site throughout the day did not question whether the circuit
9、s associated with the generator had been de-energized, locked, and tagged.Finding B: It is unacceptable to work on any energized system without proper permits and personal protective equipment (PPE). One of the causes of this mishap was a risk-taking decision based on past experience and the percept
10、ion of a low risk situation. Managers should verify that their employees know and are implementing the applicable safety policies and procedures. The following evidence supports this finding: 1. It is a common practice for some electricians to work on energized circuits without PPE and without the p
11、roper permits. Both NASA and the contractor have policies that prohibit work on energized circuits, except for a few circumstances that were not applicable in this case.2. Although the contractor has adequate policies and procedures, implementation is weak or lacking. For example, LO/TO training for
12、 contractor employees consisted of a contractor-provided “Electric” brochure handed out to each employee explaining the companys policy and procedure; the employee was expected to sign in the back of the brochure indicating that the employee had read the booklet.Lesson(s) Learned: Lockout/Tagout pol
13、icies and procedures must be followed and systems verified to be de-energized before beginning work.Recommendation(s): 1. NASA should implement a rigorous random safety inspection process. NASA should institute Mandatory Safety Inspection Points (MSIP), e.g., prior to work on electrical circuits and
14、 other energized systems. NASA should assess the on-site inspection responsibilities and determine if changes are necessary to make the process more robust. If changes are deemed necessary, augmented duties should be clarified to all safety and quality inspectors.2. 3. NASA should closely evaluate c
15、ontractor safety and health plans relative to employee training and implementation of policies for equivalence with NASAs Safety and Health Program. Continue to offer NASA in-house safety training as an option.4. NASA should require Pre-Project Safety Reviews prior to construction start. This should
16、 be more comprehensive than pre-construction meetings with a format analogous to an Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Operational Readiness Inspection (ORI), Test Readiness Review (TRR), etc. As a pre-requisite for the pre-project safet
17、y review, NASA should strongly consider the need for safety and job hazard analyses to be performed and not allow work to start until these are submitted and reviewed.5. NASA should require that construction contractors conduct daily planning meetings to review work to be performed during the contin
18、uous duty time or shift.Evidence of Recurrence Control Effectiveness: PendingDocuments Related to Lesson: JPG 1700.1, “JSC Safety and Health Handbook,“ Chapter 8.1, Electrical Safety.Mission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key
19、Phrase(s): a71 Energya71 Facilitiesa71 Human Factorsa71 Human Resources & Educationa71 Independent Verification and Validationa71 Industrial Operationsa71 Personal Protective Equipmenta71 Policy & Planninga71 Procurement Small Business & Industrial Relationsa71 Program and Project Managementa71 Risk
20、 Management/Assessmenta71 Safety & Mission Assurancea71 Test & VerificationAdditional Info: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 2003-10-01a71 Approval Name: Ron Montaguea71 Approval Organization: JSCa71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
