April 5, 2023 | Susan Napier-Sewell

Accident Investigation

accident investigation

This incident forced an accident investigation: A researcher received a minor electrical shock while troubleshooting an energized piece of equipment under the direction of the manufacturer’s technical support representative.

In this accident investigation, a research staff member discovered a highly utilized group-owned research instrument was not operating as expected. Upon consultation with the manufacturer’s technical support representative, it was recommended that the voltage on a circuit board be measured to determine the cause of the equipment failure.

Due to COVID, the difficulty in getting a service technician on-site, and the need to make progress on their research, the researcher felt self-imposed time pressures to perform the component testing themselves without consulting electrical or safety personnel. Although the Research Safety Summary and their training allows the researcher to work on equipment less than 50-volts, the diagnostic test seemed simple enough and the circuit board was low voltage. However, the researcher was not aware that the circuit board was located near an unguarded 140-volt power source.

Thus, while testing the circuit board, the researcher, who was not wearing appropriate work! He was not wearing gloves and other PPE for live electrical work over 50-volts, thus, received an electrical shock.

Analysis of accident investigation

The researcher performed work outside the scope of their training and work control authorization. By removing the instrument cover on an energized piece of equipment, they exceeded their authorization for testing low-voltage (<50 V) equipment. Their self-imposed time-pressures to quickly get the equipment working so they could make research progress as well as the perceived low risk, lead to an inaccurate assessment of the hazards of the situation and unsafe actions.

Recommended Action

Researchers should be reminded that self-imposed time pressures and advice from instrument technical support representative should not override work authorization and safety training. In this case, a qualified electrical worker should have been contacted to remove the instrument cover and troubleshoot. Researchers should employ the SCOR principles in all activities.

Can you pinpoint all the errors or missteps, including assumptions, the researcher made that were documented in this accident investigation?

Researchers should employ the SCOR principles in all activities

Safe Conduct of Research (SCOR) Principles:

1. “A healthy aspect is maintained for what can go wrong.” Always perform work while being vigilant to changing conditions or circumstances.

2. “A questioning attitude is cultivated.” Question your own actions and/or intentions when performing work. Even an apparent simple task can have negative consequences.

3. “Hazards are identified and evaluated for every task, every time.” Understand the scope of your work and realize what you are allowed and not allowed to do.

Register for a TapRooT® Root Cause Analysis training course to further your accident investigation expertise

TapRooT® Root Cause Analysis Training courses are taught all over the world. If you are interested in learning how to stop repeat accidents, register for a 2-day or 5-day course. 

We are also available to train you and your staff on-site at your workplace; contact us to discuss your needs. You may call us at 865.539.2139 for further assistance.

System Improvements, the creator of the TapRooT® System, has a team of investigators and instructors with years of extensive training ready to offer assistance worldwide. 

Featured Image content/source: Image by Gaertringen from Pixabay.

Source for content: Department of Energy (DOE), October 25, 2021 Lessons Learned 2021-UTB-ORNL-0028 “Electrical Shock During Troubleshooting Activity,” Christopher M. Kolodzie, Ph.D, Chemical Hygiene Officer, UCLA Environment, Health & Safety | Chemical Safety.

Accident, Investigations
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