Learning from Safety Incident: Building a Culture of Continuous Improvement
Explore the aftermath of an electrical fire incident, understand the recovery process, and delve into the importance of becoming a learning organization to enhance safety measures and performance. Embrace a culture that values continuous learning, openness, and trust for ongoing improvement.
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Presentation Transcript
TAKE FIVE for Safety- Booster Event Frank Craner April 1, 2025
Event Description On Thursday, March 27, 2025, at approximately 3:15 pm, there was an electrical fire in the E6 RF power supply in Building 914. responded. Building power and Emergency power was shut off. Fire/Rescue extinguishedthe fireusingextinguishers. Fire/Rescue was called and After Fire/Rescue released the building, C-AD and Electrical Safety entered the building. The appropriate electrical switches were LOTOed. Building power was restored and an electrically safe condition was established in the affected equipment. The scene was turned over to C-AD ESH. Initial assessment is that no other equipment was affected. No injuries occurred. Access to the building was limited to preserve the scene, remove the odor, and restore equipment in the building. 2
Follow Up and Recovery Equipment and Safety SMEs performed several inspections on Friday Inspection and Testing of adjacent equipment began late Friday and continued over the weekend. Booster Operations have been restored. 3
Event Categorization and Investigation Event was categorized as ORPS-High Root Cause Analysis (RCA) to be performed. In addition to equipment failure analysis, RCA will include analysis of controls (including administrative) that could have prevented this event. 4
Safety Related Questions and Conversations Initial Response Available Fire Extinguishers Emergency Reporting (x2222/Fire Pull Box, etc.) Building Safety Smoke Detection Fire Suppression Egress Paths Operation of electrical equipment Assessing building air quality Assessing damage 5
What can we (organizationally) learn from this event? A learning organization is one that values learning and is committed to facilitating continuous performance improvement. It encourages a culture of openness and trust in an environment that rewards efforts to learn from experiences. The organization recognizes Human Performance Improvement concepts and principals in problem analysis, solution planning, and solution implementation. It rewards ongoing efforts to learn from experience, learn from others, and from self-directed studies and aggressively seeks to know what it doesn t know. 6
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