On February 2, 2005, a new electrician accidentally grounded a wire with his pliers while changing out lights and ballasts,
tripping a main circuit breaker and causing a power outage that lasted two hours. The journeyman electrician was not
shocked by the 277-volt circuit.
On April 5, 2004, demolition workers removed two locks and three tags that were still applied to electrical
equipment in a facility undergoing D&D. The workers were performing electrical strip out of the facility and
removed the lockout/tagout equipment without authorization. The facility was isolated from incoming electrical
power by air gapping all wires. Workers were still required to wear appropriate personal protective equipment for
electrical work and verify zero voltage conditions before removing equipment.
On November 1, 2004, mechanics were tasked with replacing the heads on two air compressors. Two red locks and tags
were placed on the electrical supply to the compressors and a cross connect valve was opened to provide air from a
backup air compressor. As the mechanics began bleeding down the air system, low pressure alarms occurred on the main
air system indicating a leak and failure of the mechanics to close and lockout an isolation valve as required by the work
package.
On January 27, 2005, during a liquid transfer operation, some of the liquid was inadvertently transferred to the
wrong tank. Operators re-verified the position of system valves and discovered one valve that was locked as
required but was not closed, resulting in an inadvertent transfer.
3/2005
Savannah River Site F-Canyon
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