Learning from a Near Miss Incident

1. Learning from a Near Miss Incident Bruce Meaker, PE Principal Engineer PUD No.1 of Snohomish County Everett, WA NW Hydro Operators Forum Bellevue, WA May 8, 2013

2. Near Miss Incidents • The disaster avoided: • usually ignored or buried • rarely talked about

3. Near Miss Incidents • Opportunity to learn from experience • zero-cost learning tools for safety • Established error reduction technique • Aviation Industry – 65% drop in fatal accidents • Fire Rescue Services • Health care • Rail - UK

4. Storytelling

6. Jackson Hydroelectric Project 1,150 ft of head (500 psi) 111.8 MW 2 Pelton (48.5 MW) 2 Francis (8.4 MW)

7. Shutdown of 2003 • Valve seat replacement on Francis Units • Complete dewatering of penstock

8. Access door

10. Wednesday July 2, 2003 • Preparing for shutdown on Monday • Mechanical Supervisor and 2 summer hires • Summer hire - “Do the lights go inside the TSV on Unit 2?” • Supervisor - “Yes”

11. What does “Yes” mean? • Mechanical Supervisor: • Yes, we will put the lightsin through the TSV on Monday when we have the unit shut down. • Summer hire: • Yes, go ahead and do it now.

13. Summer hire: “Something we were taking apart for the supervisor started leaking!”

17. Potential losses – $15-20 M • Lives • 2 students • 3 contractors • 5 Powerhouse employees • Damage to power house equipment • Lost power revenue • Environmental damage (oil cleanup)

18. Lessons Learned DANGER CONFINED SPACE ENTER BY PERMIT ONLY Clearly mark access-doors

19. Lessons Learned All staff (including summer hires) are to attend daily “tailgate” and pre-construction meetings. All summer hires will sign a safety agreement when hired. Staff will review what is and is not appropriate use of summer hires annually. Staff will clearly communicate expectations and assignments.

20. Lessons Learned Without training and experience, we are blind to some aspects of this technology. The Baby Boomers are retiring in droves. More Gen X and Gen Y age staff will be coming on site to take their place. Getting them the training and experience to function safely is paramount.

21. What near-miss stories do you have?Do you share them?