COMPLACENCY IS YOUR ENEMY: ANATOMY OF AN ARC FLASH INCIDENT AND LESSONS LEARNED

On May 3, 2015 a serious electrical incident occurred at one of the Department of Energy's national laboratories. Preventative maintenance was being performed on 13.8 kV switchgear, which included the task of cleaning individual switchgear cubicles. A wireman unknowingly entered an energized cubicle in order to clean it with a commercial spray cleaner. When he proceeded to spray the cleaner on to the energized components, he suffered severe injuries from the resulting arc flash and blast. This paper and presentation will review the discussions, thought process, and planning decisions made from the facility perspective. These factors unknowingly added increased risk to this work activity. It will detail the event from the worker's perspective and examine how risk factors were identified prior to the incident without being addressed. Risk control measures were never put in place to prevent the likelihood of occurrence. Finally, it will describe the details leading up to the incident, the incident itself, the response, and lessons learned. The impact and value of incorporating lessons learned associated with this event into your electrical safety program emphasizes the importance of active thinking towards reducing the likelihood of similar incidents.