November 15, 2021 | Susan Napier-Sewell

Accident Investigation

Researcher receives a minor electrical shock while troubleshooting an energized piece of equipment under the direction of the manufacturer’s technical support representative. This incident forced an accident investigation.

Accident investigation background: A research staff member discovered a highly utilized group-owned research instrument was not operating as expected. Upon consultation with the manufacturer’s technical support representative, it was recommended that the voltage on a circuit board be measured to determine the cause of the equipment failure. Due to COVID, the difficulty in getting a service technician on-site, and the need to make progress on their research, the researcher felt self-imposed time pressures to perform the component testing themselves without consulting electrical or safety personnel.

Although the Research Safety Summary and their training allows the researcher to work on equipment less than 50-volts, the diagnostic test seemed simple enough and the circuit board was low voltage. However, the researcher was not aware that the circuit board was located near an unguarded 140-volt power source.

Thus, while testing the circuit board, the researcher, who was not wearing appropriate work gloves and other PPE for live electrical work over 50-volts, received an electrical shock. Analysis: The researcher performed work outside the scope of their training and work control authorization. By removing the instrument cover on an energized piece of equipment, he exceeded his authorization for testing low-voltage (<50 V) equipment. His self-imposed time-pressures to quickly get the equipment working so he could make research progress as well as the perceived low risk, lead to an inaccurate assessment of the hazards of the situation and unsafe actions.

Can you pinpoint all the errors or missteps, including assumptions, the researcher made that were documented in this accident investigation?

Recommended action resulting from the accident investigation

Researchers should be reminded that self-imposed time pressures and advice from instrument technical support representative should not override work authorization and safety training. In this case, a qualified electrical worker should have been contacted to remove the instrument cover and troubleshoot.

Researchers should employ the SCOR principles in all activities

Safe Conduct of Research (SCOR) Principles:

1. “A healthy aspect is maintained for what can go wrong.” Always perform work while being vigilant to changing conditions or circumstances.

2. “A questioning attitude is cultivated.” Question your own actions and/or intentions when performing work. Even an apparent simple task can have negative consequences.

3. “Hazards are identified and evaluated for every task, every time.” Understand the scope of your work and realize what you are allowed and not allowed to do.

Register for a TapRooT® Root Cause Analysis training course to further your accident investigation expertise

TapRooT® Root Cause Analysis Training courses are taught all over the world. If you are interested in learning how to stop repeat accidents, register for a 2-day or 5-day course. 

We are also available to train you and your staff on-site at your workplace; contact us to discuss your needs. You may call us at 865.539.2139 for further assistance.

Founded in 1988, the TapRooT® Root Cause Analysis System solves hurdles every investigator faces

TapRooT® Root Cause Analysis Training System takes an investigator beyond his or her knowledge to think outside the box. Backed with extensive research in human performance, accident investigation, and root cause analysis, TapRooT® is a global leader in improved investigation effectiveness and productivity, stopping finger-pointing and blame, improving equipment reliability, and fixing operating problems.

System Improvements, the creator of the TapRooT® System, has a team of investigators and instructors with years of extensive training ready to offer assistance worldwide. 

Accidents, Investigations
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