Key learnings from a High Potential Incident.
HPI OSH Alert #464
Date of incident: 23 January 2015
Safety Flash issued: 28 January 2015
A Mechanical Fitter was performing a routine maintenance task (De-ragging pump) at a wastewater pump station. While completing this task, the amp meter located on the front of the electrical switchboard dislodged and fell into the starter control cabinet. The Mechanical Fitter accessed the rear ofthe panel, made contact with the amp meter and received an electric shock.
As a result of the force of the electric shock, the injured person sustained two dislocated shoulders and a fractured shoulder blade. The voltage present was sufficient to cause an electrical current that could have caused a fatality.
Why did this happen?
Unauthorised electrical work conducted by opening the starter control cabinet which led to contact being made with the electrical terminals on the back of the live amp-meter. A breach of the Tagging and Isolation Procedure WC-OSH-109 led to an inadequate isolation of the panel. Failure to adhere to Safe Job Planning process. The deterioration of the amp-meter surround had not been identified through maintenance inspections.
What will our organisation do to stop this from happening again?
Organisational corrective actions identified as applicable to Water Corporation are as follows:
- Alterations to switchboards and cabinets, where needed:
- establish a Standard for existing and new electrical switchboards and cabinets that provides for effective isolation including testing/verification
- conduct an audit of all switchboards/cabinets against the above Standard
- aggregate results of the audit and develop a State wide plan to address any gaps
- arrange installation and/or upgrade of necessary components to enable effective isolation to be achieved on cabinets
- Tagging and Isolation
- amend WC-OSH-109 to provide further instruction and guidance on the nature of testing/verification of electrical system isolations.
What key learnings can you discuss with your team to stop this from happening?
- Only undertake activities for which you are trained, competent and authorised to do
- Does our team ever have to conduct electrical work? If so, are we fully aware that this is to be performed by Licensed Electrical Workers?
- What is our understanding of Safety Essentials, in particular, Electrical?
- Are we asked to do work where safety protocols are not exactly followed to get the job done? How do we escalate this if we think we can’t follow the safety protocols?
- Work continues to be undertaken on energised systems (water mains, sewer systems, pump station cubical, etc) when they should have been isolated.
- For the type of work our team does, when must the equipment/asset be isolated?
- When isolating live systems to undertake scheduled maintenance, what additional planning and scheduling might be needed?
If you would like further information about anything included in this HPI OSH Alert, please contact Charis Neumann, Snr OSH Analyst Incident Management, on (08) 6330 6629.