Defiance Injury Incident

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Electrical Injury Incident Review
Date of Occurrence Aug. 30, 2000 by Lynn
Saunders GM - WFG Utilities Services 313-974-9919
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Electrical Incident / Injury Review
Highlight the events leading up to the incident.
Discuss observations and contributing factors.
Discuss recommendations for corrective actions.
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Background
R1 Substation R
R2
(Top View)
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Switching Plan Developed
Shows the order by which the lockout would occur!
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Site Documented Policy for Substation Switching
Includes the Use of this form
FORM WAS NOT USED!
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Cells within the Zone of Protection
(Top View)
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Cells within the Zone of Protection
(Top View)
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Relevant Events Leading Up to the Incident
(Top View)
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Relevant Events Leading Up to the Incident
(Top View)
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Relevant Events Leading Up to the Incident
On Monday, Aug28 Employee reviewed progress of
the work with chief electrician
After the review, it was mutually agreed that it
made sense to expand the scope to include
maintenance / cleaning / inspection for all of
the substations in plant 2East.
(Top View)
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Zone of Protection Necessary to Safely Enter
Compartment A4 on R2 Side
(Top View)
This Zone of Protection would have required a
completely different lockout scheme and
operational configuration!!!
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Relevant Events Leading Up to the Incident
On Monday, Aug28 Employee reviewed progress of
the work with chief electrician L. Warnke.
After the review, it was mutually agreed that it
made sense to expand the scope to include
maintenance / cleaning / inspection for all of
the substations in plant 2East.
(Top View)
On Tuesday, Aug 29 Completed repair of the A4
terminations for R1 and R2.
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Relevant Events Leading Up to the Incident
(Top View)
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Barriers in Substation R2 - Switch Cubicle A4
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Barriers in Substation R2 - Switch Cubicle A4
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Barriers in Substation R2 - Switch Cubicle A4
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Barriers in Substation R2 - Switch Cubicle A4
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Barriers in Substation R2 - Switch Cubicle
A4 where the Employee was injured
Load Side Fingers
Top Barrier
Line Side Fingers (Supply)
Bottom Barrier
Shutter (Moving Barrier)
These barriers guard against incidental /
accidental contact with energized parts behind
them
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Shutters Lifting During Switch Insertion
Shutter in Lifted Position Allows Switch to be
Plugged In
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Barriers in Substation R2 - Switch Cubicle
A4 where the Employee was injured
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Observations / Contributing Factors
Employee failed to follow a primary
rule RE-VERIFY ISOLATION - LOCKOUT PROCEDURE!!!
There was no documentation 13.8kV Lockout
Worksheet for the tasks that were being
executed. Established local procedures were not
followed.
Current planning procedures lack necessary detail.
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Recommendations for Defiance Corrective Action
Management must demonstrate commitment to current
policies and procedures!
Add to Existing Planning Procedures /
Documentation Package
Detailed, sequential task list
Graphical / Pictorial representation of the Zone
of Protection.
Detail of other peripheral hazards contingency
plans.
Consider lockable mechanisms to secure cabinets
that are not within the zone of protection
created. (Prevent task creep)
Consider use of visual controls for use during
the job to highlight or identify those
compartments that are not within the zone of
protection created. Make these signs noticeably
different than standard sign.
Investigate the possibility of using Personal
Voltage Proximity Detectors
Reference ESWP document at http//wfg.gm.com
/WFGP001.nsf/public/Utility_ReferenceMaterials
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Planning Procedures / Documentation Package
Document to be completed by the Supervisor, or
the person that will perform the tasks
General Description of the Work to be Completed
List the Persons involved in the execution of
tasks
Identification of Shock/Flash Approach Boundary
Requirements
Identification of any special communications
equipment requirements
Address how non-qualified persons will be kept
clear of the electrical hazards.
CERTIFY that prints, manuals, other relevant
documents have been reviewed.
Contain a detailed sequential task list.
Include a tool to physically identify zone of
protection, peripheral hazards and plan for
protection from them.
Review of Emergency Procedures
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Planning Procedures / Documentation Package
General Description of the work to be completed
A verbal description WHAT is to be done, and
WHERE it will be done.
Can be used to develop the Lockout Plan /
Switching Schedule.
A detailed sequential task list.
Tool for use while performing the tasks
ANYTHING NOT ON THE LIST IS NOT TO BE
DONE. (Prevents Task Creep)
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Planning Procedures / Documentation Package
Include a tool to physically identify the
boundary.

• Safety One-Line Diagram.

• Pictures of the job site.

• Plot plan / Substation Layout

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Planning Procedures / Documentation Package
Lastly, management owns the responsibility to
ensure that the planning process has been
followed and the proper players participated.
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QUESTIONS / COMMENTS