Lesson Learned Statement:There are a variety of lockout devices available from various manufacturers to accommodate the diversity of molded case circuit breaker applications. Many of these lockout devices are designed to be applied to specific types of breakers. It is essential to ensure that these lockout devices are properly installed and meet the applicable provisions of the site hazardous energy control procedures. Ensure the lockout devices are durable. When using breaker lockout devices, be sure the device used will meet the same substantial protection requirements as a lock. If personnel are unsure of the correct breaker lockout device, they should ask their supervision for guidance.Discussion:Two Maintenance Site Services (MSS) Subcontractor electricians were performing electrical maintenance. A breaker lockout device was applied to a 200 amp, single pole, molded case circuit breaker that provided service to a secondary panel where workers were installing a new circuit for a photocopier. Because the design of the breaker toggle did not permit ready and secure attachment of the breaker lockout device being used, the electricians attempted to secure the lockout device by applying electrical tape to the tapered breaker toggle. The secondary panel was also isolated by opening the main breaker but was not placed under lockout. After removing the cover on the secondary panel, the electricians verified the absence of voltage using a multimeter. The Building Operator went to the primary panel to verify the single source isolation. When the primary panel door was opened, the breaker lockout device and personal locks fell to the floor. The open breaker did not close. The two electricians were immediately notified and work was stopped while they attempted to reinstall the device. The wiring connections in the secondary panel had been completed; however, the panel cover had not been reinstalled. While attempting to reinstall the breaker lockout device, the electricians and Building Operator determined that the lockout device was inadequate and unacceptable for the intended application. (Subsequent investigation collaborated this observation; the lockout device was designed for a double pole breaker.) The electricians reinstalled the secondary panel cover to put the work site in a safe condition (removed the potential hazard of exposure to electrical contacts in the secondary panel) while a guard was stationed at the primary panel to prevent inadvertent operation of the breaker used for electrical isolation of the work area. Post maintenance testing indicated a satisfactory installation of the new circuit for the photocopier.The MSS Subcontractor issued a stand-down of all single-source electrical Lockout/Tagout (LO/TO) work activities utilizing breaker lockout devices that attach to the breaker handle. These types of applications are typically found in a power panel or electrical distribution panel. Analysis:Upon consideration of the event, the electricians recognized that the improvised application did not provide the level of protection necessary for their own safety. Personnel should have the training, education, and experience commensurate with their assigned responsibilities (ISMS Principle 3). When the electricians had difficulty placing a single pole breaker lockout device (original) on the 200 amp breaker, they substituted a second lockout device that was larger since it was designed for a two pole breaker. Unknown to the electricians, the two pole breaker lockout device was not the proper device for the intended application. The electricians applied tape on the tapered breaker toggle to improve the attachment of the two pole breaker lockout device. Control of Hazardous Energy (Lockout/Tagout), 29 CFR 1910.147 (c)(5)(ii)(C)(1), requires that lockout devices "shall be substantial enough to prevent removal without the use of excessive force." The taped toggle did not permit secure attachment of the breaker lockout device used. Both the utilization of the two pole device and the taped toggle which resulted in an insubstantial anchorage are the direct result of insufficient training on the selection and proper application of breaker lockout devices. There are a variety of lockout devices available to accommodate the diversity of applications. Subsequent investigation showed the original single pole lockout device, which was not used, would fit on the breaker and effectively meet all performance criteria for lockout devices on the breaker; but required effort to apply. Additionally, product literature was obtained indicating that snap-on cleat accessories are available for lockout devices to specifically fit the breaker manufacturer's product. Furthermore, there are hasp accessories that are available for lockout devices to specifically fit the breaker manufacturer's product that can be installed by technicians in the field.It is essential that lockouts/tagouts are properly installed prior to beginning work. Employees need to be trained to ensure that they know, understand, and follow the applicable provisions of the hazardous energy control regulations. The employees must use only LO/TO devices authorized for the particular equipment or machinery. There are different manufacturers and types of molded case circuit breaker lockout devices. Each device is made to be applied on specific types of breakers by specific manufacturers (i.e. single phase, three phase, single pole, double pole, Westinghouse, General Electric). Employers must provide lockout devices for equipment and ensure that they are durable, standardized, and substantial. Personnel must stop work and notify their supervision if they have difficulty in applying a secure lockout/tagout. Durable, standardized, and substantial lockout devices were available. Improvised solutions are unacceptable and may only provide temporary protection. Improperly established lockouts and tagouts can evoke a false sense of security. An inadequate lockout can expose workers to unexpected hazards for which no other protection may have been provided. This event highlighted the need for personnel to be adequately trained to properly apply lockout devices. Had the electricians' supervision or Safety Manager been contacted, a secure compliant lockout device would have been applied. Recommended Actions:Ensure that LO/TO training includes discussion that breaker lock devices must be selected for the specific application and must meet the substantial protection requirements as a lock. If possible, provide sample breaker and lockout device for training demonstration (show and tell).Review other Department of Energy Lessons Learned related to LO/TO such as; 2002-RL-HNF-0017 L-2002-OR-BWXTY12-0104 1999-ALO-WID-0007 Y-1997-OR-LMERX10-1201 Originator:Doug Lovette, Bechtel Jacobs Company, LLC; 865-241-5224Validator:David Kelsey, J. A Jones Co.Contact:Joanne E. Schutt, 865-483-0554Name Of Authorized Derivative Classifier:Samuel C. HowardName Of Reviewing Official:D. C. LannomPriority Descriptor:Blue / InformationKeywords:lockout; tagout; breakerReferences:Lessons Learned:2002-RL-HNF-0017 L-2002-OR-BWXTY12-0104 1999-ALO-WID-0007 Y-1997-OR-LMERX10-1201 Information in this report is accurate to the best of our knowledge. As means of measuring the effectiveness of this report please use the "Comment" link at the bottom of this page to notify the Lessons Learned Web Site Administrator of any action taken as a result of this report or of any technical inaccuracies you find. Your feedback is important and appreciated. DOE Function / Work Categories:Conduct of Operations - Lock and TagMaintenance - Electrical Maintenance - Facility ISM Category:Perform WorkHazard:Electrical / NEC
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