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Causal Factors Analysis: 12-36 Conference Room Renovation Temporary Modification

2. CFA for Temporary Mod. Event SummarySaturday, January 10, 2009, a subcontractor electrician cut an energized (110 volts) wire during preparations to connect new electrical wires within a junction box in the executive conference room of Building 12-36. No injury.Electrician Working under an ap

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Causal Factors Analysis: 12-36 Conference Room Renovation Temporary Modification

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    1. 1 Causal Factors Analysis: 12-36 Conference Room Renovation Temporary Modification January 2009 Event

    2. 2 CFA for Temporary Mod Event Summary Saturday, January 10, 2009, a subcontractor electrician cut an energized (110 volts) wire during preparations to connect new electrical wires within a junction box in the executive conference room of Building 12-36. No injury. Electrician Working under an approved Lockout/Tagout (LOTO) Permit Working from a ladder Wearing leather gloves, safety glasses and shoes

    3. 3 CFA for Temporary Mod Event Facts Scope of work for conference room renovation project inadvertently changed. Temporary power provided to fire alarm control panel (FACP) Subcontractor rather than B&W crafts landed wiring for new multi-tone/strobe devices Change in scope not effectively analyzed Temporary power back fed 110 volts into boundary of original LOTO

    4. 4 CFA for Temporary Mod

    5. 5 CFA for Temporary Mod

    6. 6 CFA for Temporary Mod

    7. 7 CFA for Temporary Mod

    8. 8 CFA for Temporary Mod SUMMARY Work that involves subcontractor and contractor workers is vulnerable to misunderstandings of who is controlling each aspect of the work scope. FR can familiarize themselves with Contract Scope of Work. Monitor understanding of lockout/tagout boundaries – significance increases with multiple sources of energy and multiple craft disciplines. FR can review LO/TO permits and ask for boundary diagrams/definitions. Monitor use of air gaps (lifted leads) and appropriate application within a LO/TO. FR can monitor the use of lifted leads and how they are controlled. Inability to detect changes in scope of work and re-initiate the ISM core functions. FR can question if changes to the work plan constitute a scope change. Shared insight on effective control of balance of plant systems. How are balance of plant system configurations at other sites effectively managed?

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