REG NASA-LLIS-1085--2000 Lessons Learned Mishap Investigation Board Report Findings for the GSFC Building 3 13 14 Electrical Manhole Close Call of December 26 1998.pdf

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1、Lessons Learned Entry: 1085Lesson Info:a71 Lesson Number: 1085a71 Lesson Date: 2000-03-24a71 Submitting Organization: GSFCa71 Submitted by: Suzanne Johnson / Eric RaynorSubject: Mishap Investigation Board Report Findings for the GSFC Building 3/13/14 Electrical Manhole Close Call of December 26, 199

2、8 Abstract: An attendant left workers unattended in an electrical manhole, suggesting a lax attitude towards confined space guidelines.Improve training, audit, and onsite management of high voltage electrician employees.Description of Driving Event: On December 26, 1998, two employees were left work

3、ing in an electrical manhole unattended in violation of confined space entry requirements. The Electrical Manhole incident occurred in and around Electrical Manhole #PM-70 (labeled as a Telephone Manhole) which is located on the south side of Building 13 at GSFC. All Personnel involved in this incid

4、ent were civil servants from the Electrical Distribution Section (Code 227. 1).A call came in to the GSFC emergency console at approximately 5:30 a.m. on December 25, 1998 that there was a loss of power on feeder 7 in buildings 3/13/14. Electricians worked throughout that day and into the next to is

5、olate and identify the problem. It was determined to be a fault on phase A feeder B-7 located in manhole PM-70. By the end of the 1 shift/beginning of the 2 shift on December 26, the four workers involved in the incident began working together to fix the problem.The four workers (two from the 1 shif

6、t and two from the 2 shift) arrived at PM-70 and began setting up to complete the task. The workers informally discussed the task prior to commencing work. One of the V shift workers assumed the lead although there was no official task leader. Testimony is conflicting on whether or not proper confin

7、ed space entry procedures were followed. Although there was some testimony that a gas/air check was completed prior to workers entering the manhole (MH), Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-there is no documentation to support that assert

8、ion. The investigation did not reveal a confined space entry permit, a gas/air check log book entry or evidence that a work life station was established per the GSFC Facilities Maintenance Division (FMD) (Code 220) Policy and Operational Procedures for Confined Space Guidelines or OSHA Standard 1910

9、.146 requirements (References C and D, respectively).The two 1 shift workers entered the manhole and commenced work (now referred to as the MH workers) and the two 2 shift workers remained above ground (now referred to as the AG workers). The MH was very small so the AG workers removed the ladder to

10、 give the MH workers more room. While the MH workers were working in the MH, one of the AG workers (now referred to as AG 1) left the area to do the east sub-station checks. The second AG worker (now referred to as AG 2) remained as safety monitor above the MH. No one informed the MH workers that AG

11、 I had left.The MH workers requested that AG 2 get them a specific tool. AG 2 informed the MH workers that the tool was not at the worksite and he would have to retrieve it from the shop (located in Building 24). The MH workers acknowledged that AG 2 would be leaving the site. Since they did not kno

12、w AG I had left, they were unaware that AG 2 leaving left them in the MH unattended. AG 2 believed that retrieving the tool would only take a few minutes and that AG I would be returning shortly, probably before he returned.The MH workers discovered they were alone when they called for AG I and got

13、no response. One MH worker stood on the shoulders of the other to peer out of the MH and saw AG I in his truck. The MH workers immediately proceeded to exit the MH and confront AG 1. The MH workers believed that AG I was in the truck to stay warm rather than monitoring the MH. At approximately the s

14、ame time, AG 2 returned to the site and observed the MH workers were angry at having been left unattended in hole. Testimony does not indicate that the four workers cleared up what exactly had transpired at this time. Testimony indicates that the time the MH workers were left unattended was from 1 t

15、o 5 minutes. The workers continued to work on the task after this incident occurred (the job was not completed for several days).Lesson(s) Learned: The primary cause of the electrical manhole incident is an error in judgment made by the attendant that left the workers in the manhole unattended. The

16、Mishap Investigation Board (MIB) identified two contributing causes. Testimony indicated that non-adherence to the Code 220 confined space guidelines was the norm in this organization at the time of this incident. This mode of operation was either condoned by or unknown to management. All workers in

17、volved in the incident had received some confined space training; however records indicated that it was not complete or recent. The attendant had not received training while a GSFC employee. The MIB believes that inadequate training contributed to the relaxed attitude of employees towards adherence

18、to the confined space entry guidelines, which in turn contributed to the attendants decision.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-A lax attitude towards safety has a cumulative effect: Lapses in OSHA-required training leads to non-adherenc

19、e to important safety-related practices and to employees that do not have safety upper most in their minds. New employees get the impression that safety is not all that important. Lapses in adhering to safety requirements and/or enforcement of adhering to safety requirements leads to the perception

20、that the rules are not based on a real need to prevent mishaps (i,.e., we never follow the rules and nothing bad happens). Eventually, these lapses will result in a mishap.Recommendation(s): 1. Require all new high voltage electrician employees receive Confined Space training at GSFC. Develop and im

21、plement Code. 227.1 policy that requires yearly refresher training for all employees that work in confined spaces. Establish a process for regular audits of Confined Space work sites to insure that workers are following the Code 220 Confined Space Entry Guidelines. Results of audits should be docume

22、nted and briefed to Code 220 management on a regular basis.2. Develop and implement an official Code 227.1 policy to: a) have assigned task leaders for every job; b) require a tail-gate meeting is held with all team members and the role of each member of the team is defined; c) the task leader be in

23、formed of any team members departure from the work site.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 ScienceAdditional Key Phrase(s): a71 Communication Systemsa71 Emergency Preparednessa71 Energya71 Facilitiesa71 Human Factorsa71 Indust

24、rial Operationsa71 Logisticsa71 Mishap ReportingProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Mishap Report References: Mishap Investigation Board Report Findings for the GSFC Building 3/13/14Additional Info: Approval Info: a71 Approval Date: 2002-02-12a71 Approval Name: Jay Liebowitza71 Approval Organization: GSFCa71 Approval Phone Number: 301-286-4467Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-