SAFETY FLASH Report

INITIATED BY:
CORPORATE GROUPS
HYDRO
FOSSIL
NUCLEAR

Notice No. 06-0054

Issued: 06.09.06

OPG Records #08960.2424 T5

Initial Communication

yy.mm.dd

Summary of Investigation

Type of Event

External Safety Incident

Title

Location
Type of Event
Description

Fort Calhoun Nuclear Station, Omaha Public Power District, Omaha, Nebraska

MRPH Rating

N/A

Electrical Arc Flash

Utility electrician suffered second and third degree arc flash burns to the arms, face, and torso.

Date of Event

August 26, 2006

Event Summary

This external incident was identified through OPGs OPEX (Operating Experience)
Program.
On Saturday August 26, 2006, at 0945 a.m. an OPPD Fort Calhoun Station electrician suffered
second and third degree flash burns to the arms, face, and torso.
The arc flash occurred when the electrician used a high voltage detection device (hot stick) in a
spare 480 V breaker cubicle, which caused a phase-to-phase short resulting in the arc. Entry into
the 480 V cubicle was not part of the pre-planned job and approved work scope and was not
discussed during the pre-job briefing. The electrician took this action without consulting with his
crew leader, the other electrician assigned to this task, or anyone else. It is surmised that the
electrician decided to enter the 480 volt breaker cubicle to determine if the hot stick was
functioning properly.
The electrician did not don the required personal protective equipment for accessing the breaker
cubicle (Nomex suit, gloves, and face shield) as set out in the station safety manual.

Injuries/Damage

Utility electrician suffered second and third degree flash burns to the arms, face, and torso.
Damage to the electrical cubicle and electrical components.

Causes

Unknown
Apparent
Root

A full investigation into the exact causes and contributors is currently underway, but several key
learnings are evident:
This was a relatively routine task (live-dead-live voltage check), for the electrician [STAR Stop,
Think, Act, Review]
A.

There was a question about how the functionality of the voltage detection device (hot
stick) could be tested. [Questioning Attitude and Conservative Decision Making].

B.

The electrician was in a spare 480 V breaker cubicle that was outside the original work
scope and procedure for the task he was performing. [Our Human Performance Tools
of: Procedure Use, Peer Checking and Questioning Attitude]

C. The proper PPE for being in a 480 V breaker cubicle was not utilized. [Procedural
Compliance]

Actions Taken

Recommended
Action for Others

The employee was transported via helicopter to the Creighton University Hospital and then to the
Saint Elizabeth Burn Center in Lincoln, NE. Electrician remains in hospital.
Stand Down to review the incident conducted within the utility.
OPEX Flash Report initiated within OPG.
Communicate this event to staff within OPG who perform electrical work to reinforce
expectations, including:

Procedural compliance
Questioning Attitude, Conservative Decision Making, STAR, Peer Checking
Safety procedures for performing electrical work including protection from electrical arc
flash incidents

Below is Summary of Key Learnings as published at Fort Calhoun following the incident:
A.

B.

Performing a live-dead-live voltage check is an everyday routine task for

electricians. In this case, however, the method that the electrician chose to use to
perform the task was NOT routine. Appropriate planning, preparation, and safety
requirements were not followed. [Guard against complacency]
1.

Tasks that seem routine are not routine when they are performed in a manner
or method that are outside of our normal procedures or process controls. When
a task cannot be performed according to approved procedures and processes,
let your supervisor know and get the issue resolved before you proceed. Make
it a point to ensure you have the appropriate training or oversight so the task
can be done safely.

2.

Even the most routine tasks can cause problems if we are not engaged when
we perform it. Guard against complacency by paying close attention to the task
and rigorously following the procedure.

There was a question about the functionality of the current testing device (hot stick).
[Dont answer your own question].
1.

C.

When questions arise about on-going work STOP and get the right people
involved to get the question addressed BEFORE proceeding. By doing this we
bring to bear the collective experience of the team to solve the problem rather
than the person who discovered or is struggling with it. Your first and primary
point of contact is your supervisor. Other people to contact include the OneStop-Shop, Work Week Manager (on-line), or Shift Outage Manager (Outage).

The electrician entered a spare 480 V breaker cubicle that was outside the original
work scope and procedure for the task he was performing. [Our Human
Performance Tools of: Procedure Use, Peer Checking and Questioning Attitude]
1.

If you find yourself in a situation not covered by the procedure or work

document, the right thing to do is STOP and contact your supervisor BEFORE
proceeding. Your supervisor will help determine if a change to the procedure or
work document is needed prior to proceeding OR if another procedure applies.

2.

If you are unsure if the procedure or work document applies for your task, get a
PEER CHECK from an experienced co-worker. This helps prevent getting
outside your scope and procedural bounds.

3.

D.

The Electrician did not wear the proper PPE for being in a 480 V breaker cubicle.
[Our key platform of Being Deliberate (with our actions under control) and Following
the Rules].
1.

Contact

IMS No./SCR No.

For Site Use Only

Local Site
Disposition
94343 Rev 06-04

Management
Contact:
Safety
Contact:
N/A

If you find yourself Distracted, Uncomfortable, or Confused (DUCs), then STOP

and verify that you are still within the bounds of the procedure or work
document. If you are still not certain, contact your supervisor and get the
necessary changes made BEFORE proceeding.

FCSG-15; FCS Safety Manual has specific requirements on the use of Personal
Protective Equipment (PPE) that must be properly worn during work in the
plant. Use of the equipment is MANDATORY. By being deliberate and
following the rules with PPE we help ensure our safety and the safety of others.

Greg Jackson

Phone
Number
Phone
Number

(905) 839-1151 x8501