Core Drilling into an Energized 13.2 kv Manhole Near Miss

1. Core Drilling into an Energized 13.2 kv Manhole Near Miss Los Alamos National Laboratory, TA-55 Plutonium Facility Presented by Dan Carter, Facility Representative at TA-55

2. Event Summary • Electricians drilled multiple 8 inch holes/cores into an electric utilities man hole containing energized 13.2 kv cables. • The actual event occurred in December 2010. • The concern was identified on January 20, 2011 during a walkdown of the work to be performed. • The drilling tool came within approximately 2 inches of the energized cable.

5. Immediate Actions • The Facility Operations Director suspended Nuclear Materials Safeguards and Security Upgrade Project (NMSSUP) operations on January 21, 2011 pending outcome of a Critique. • Critique was held on January 24, 2011 • NMSSUP management provided actions to ensure IWD requirements would be reviewed in pre-job meetings, and • What actions should be taken if it is determined that job hazards and proper controls were not in the IWD prior to resuming construction activities.

6. Description of Events • Additions were being made to the 13.2 kv electrical system as part of the Nuclear Materials Safeguards and Security Upgrade Project (NMSSUP). • Two IWD’s were to be generated, the first was to install a new manhole/conduits, the second was to pull cables and splice into the 13,200 volt service line in an existing manhole. • Work under the first IWD was to be performed by electricians/wiremen. • Work under the second IWD was to be performed by utility linemen at a later date.

7. Description of Events, cont. • Work under the first IWD started in mid 2010. • A pre-job was held but the IWD was not reviewed. • The first IWD hazard analysis did not include work on or near energized 13.2 kv lines. • The conduit tie-ins, cable pulls and splicing including coring of 6 holes in the existing man- hole should have been performed under the second IWD.

9. Description of Events, continued

11. Barriers that failed • Formal Integrated Work Management Process was not implemented • This resulted in the wrong personnel performing work using the wrong IWD in close proximity to energized 13.2 kv cables

12. Step 1: Define the Scope of Work • The Person-in-Charge worked from memory and his memory was inaccurate. • Failing to use the IWD on the day the work was performed did not give him the opportunity to recognize that the IWD only applied to new manholes. • Wiremen failed to review and use the IWD. • Personnel perceived a lack of value of IWD’s in daily work execution.

13. Step 2: Identify and Analyze Hazards • The 13.2 kv hazard was not formally identified and analyzed. • The wiremen analyzed the hazards based on their knowledge, skills, and abilities as wiremen • Their analysis included a discussion of hazards with the site ESH&Q representative and did not include a review of the IWD.

14. Step 3: Develop and Implement Preventive Measures and Controls • The IWD was not originally intended to cover drilling into the existing manhole and did not identify or analyze the hazards. • Informally they considered de-energizing the cables but determined it would have a negative impact on facility operations and would delay work execution. • Based on their informal hazard identification & analysis the crew developed and implemented a set of measures and controls (on-the-spot) that would prevent them from hitting the energized cables.

15. Step 4: Perform Work safely • From June through November 2010, the PIC used the IWD, hold points were signed off, the IWD was reviewed and signed by the workers. • As the months passed by the PIC’s daily use of the IWD diminished and it became a work authorization document to assign work. • The PIC forgot the details of the IWD and assumed he could safely assign wiremen to perform core drilling and conduit installation under the IWD. This should have been performed by linemen. • The IWD was not used/reviewed to confirm required controls were in place, nor did they confirm the qualification, training of workers and authorization required by LANL to perform this task.

16. Step 5:Provide Feedback • Workers did not provide feedback to the PIC regarding their jurisdictional question. • The wiremen sensed that the work might be linemen work. • The foreman contacted their union steward, but neither the steward nor the linemen foreman ever notified the PIC of their concern.

17. Conclusion • The root cause of this event was a breakdown in the implementation of LANL’s formal Integrated Work Management Process

18. Corrective Actions/Lessons Learned • A question regarding jurisdiction should result in a pause of work and review of related safety concerns. • Believing you can perform work safely is not the same as being trained and qualified to perform work safely. • Balancing multiple work activities in a changing work environment requires: • PICs to make frequent decisions on whether to stop work and generate new work control documents • Workers to continually remember which IWD they are working under for the task at hand • IWD’s be reviewed prior to start of work.

19. Corrective Actions/Lessons Learned cont. • Electrical Safety Officers are to independently review all electrical IWD’s. • All moderate and high hazard work must have documented daily pre-job briefings. • Jurisdictional direction with union is to be updated to clarify medium and high voltage work and clarification on Pause Work in the case of safety implications.

20. Corrective Actions/Lessons Learned cont. • Perform briefings on Scope Change and Electrical Safety to: • Electricians • Managers • Superintendents • Work Control Team Leads • Planners and Maintenance Coordinators

21. Any Questions • If you have any question in the future please contact Dan Carter at: • 505-606-1883 • dcarter2@doeal.gov