Safety Lesson from Capacitor Arc Flash Incident
Learn from a capacitor arc flash incident involving improper discharge procedures and assigning work to inexperienced groups. The outcome resulted in injuries due to lack of safety protocols and employee concerns being overlooked. Recommendations emphasize the importance of having proper procedures and conducting zero-energy verification before working on electrical systems.
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Presentation Transcript
TAKE 5 FOR SAFETY E. Lessard May 22, 2018
Capacitor Arc Flash Event at ANL The event occurred when an engineer was placing a safety shorting wire onto a 15 kJ rated capacitor terminal post following the manual discharge process The discharge process did not include a zero-energy verification step and relied solely on a hard discharge as the means of ensuring the discharged state of the capacitor 2
Assigning the Work The capacitors were being tested for a beamline pulsed magnet power supply project The capacitor, believed to be in a safe state, was in fact not safely discharged, and a disruptive discharge with short circuit flash occurred when the employee tried to attach the clip lead Unknown to the workers performing the task, there had been a complete testing procedure with safety protocol identified The work task was assigned to a different work group less familiar than that which had done the task previously 3
Work Performance and Outcome The workers relied on a process intended to achieve zero energy state without verification as required Employee concerns expressed at a pre-work informal project review were not addressed Recommendation to identify full scope of work and overall project milestone was never completed The work proceeded without a work plan or procedure The event resulted in second degree burns to one engineer s left hand and ringing in the ears to the second employee following the concussive energy discharge 4
Lessons Learned: Have a procedure, work plan or hazard analysis for the work being performed Conduct zero energy verification prior to shifting to an electrically safe work condition These address contributing causes: 1) inexperienced work group and 2) belief that capacitors were discharged Do they speak to not addressing employee concerns during pre- work review? 5
