Attachment 1:-----Root Cause Investigation Template

							8-11-02
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Report Number: SI #3423
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Date: August 11, 2002
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Date of Incident: July 5, 2002
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              RCI Report on DC Electrical Contact
               Underground Cable Splicer NWA
               999 E. Touhy Ave Des Plaines, IL
                            C-985
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REPORT BY:

Jesse Reynolds TI CS.
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INVESTIGATION PARTICIPANTS:

Jesse Reynolds   TI CS                      Jenna Williams      Safety
Arnold Brown     TI NE                      Denney Roper        Const Supt NWA
Bob Shuttleworth EAG                        Tom Colclasure      Methods
Erika Bonelli    DMC                        Timothy Johnson     Field Supervisor NWA
OES Operations   NWA                        CrewLeader           NWA
Two Cable Slicer NWA
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EXECUTIVE SUMMARY:
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An Underground Cable Splicer received an electrical shock while disconnecting leads
from a hi-pot test set. The electric shock was received due to the fact high voltage
testing procedures were not followed. The Technical Investigation Engineer turned the
hi-pot unit on after the splicer was told the unit was off and grounded. All regional
Technical Investigation (TI) Managers are to review the high voltage testing procedures
with department personnel.
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EVENT DESCRIPTION:
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On July 5th Technical Investigation Engineer (TIE 1), Underground Crew, and an
Operating Electrician Special (OES) were dispatched to locate a cable fault on C-985 at
999 E.Touhy in DesPlaines. When the Underground Crew arrived, the OES informed the
crewleader there was a C phase fault on the down feed from fused disconnects 43066.
After testing and grounding the leads at the pole, the Underground Crew isolated C phase
conductor from the primary side of the transformer and the OES removed the grounds
from the cable pole to allow TIE 1 to locate the fault. TIE 1 arrived at the site a few
minutes later and instructed underground crew to connect his hi-pot leads to C phase in
order to begin testing procedures. The job briefing sheet was not signed by the parties
involved which included the OES, UNDG crew, SUPV, and 2 TIE’s. After taking radar
shot, TIE 1 walked the route of the cable attempting to pin point the fault. It was
determined the tentative location of the fault was under Touhy Avenue.
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TIE 1 aborted the fault-locating task and started restoration procedures for the customer.
The hi-pot testing equipment was turned off by TIE 1 at this time.
The Underground Field Supervisor, TIE 1, and, two underground splicers went in the
vault to gather nameplate information from the vault’s two transformers. This
information was needed to size the generator for restoration purpose. They also discussed
how the generator was going to be connected. Their plans were to isolate the down feed
cable from the fused disconnect in the vault and use a generator to energize both
transformers. After the discussion TIE 1 was asked by the crew leader whether or not the
hi-pot set was off and grounded. TIE 1 replied, yes. As TIE 1 was exiting the vault, he
stopped to speak to TIE 2 who arrived at the site to relieve him. TIE 1 briefed TIE 2 on
the situation. TIE 2 returned to his vehicle to get his fault locating equipment. The
underground splicer tested the hi-pot leads dead and touch grounded the cable then
started removing the test leads. TIE 1 returned to his vehicle and turned on the hi-pot set
simultaneously as the underground splicer was attempting to disconnect the hi-pot leads
from the cable without wearing high voltage gloves. The underground splicer received a
DC electrical shock of an undetermined voltage. An ambulance was called and the splicer
was transported to the hospital. He was released on the same day with no injuries to full
duty.
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Approximately seven years ago in Chicago a TI engineer turned on a high pot set while
another TI engineer was disconnecting the leads from a cable. The engineer
disconnecting the cable received a severe electrical shock of undetermined voltage in a
very similar fashion.
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ANALYSIS METHODOLGY:

   Task Analysis was used to develop a timeline of events and to analyze the sequence
    of events and tasks that were performed.
   Tap Root Analysis was used to analyze human performance factors.
   Interviews were held with OES, Underground Crewleader and Splicers, TI Engineer
    and other subject matter expert to gather and analyze facts.
   Reference material included: overhead troubleshooting guide, ODS ticket,
    statements from on site personnel, feeder maps, site diagram, and Safety Rule Book
    Sections (410.08.7, 401.01)



WHAT WENT WELL:

   Crew initiated emergency medical service (EMS)

ROOT CAUSES:

   High Voltage Tests procedure was not followed
    F.13
    “All capacitors, regardless of voltage, should be treated as though they were
    energized unless short-circuited. When a capacitor or any associated apparatus ( in
    this case the hi-pot thumper contains and uses a capacitor for its functioning) is
    disconnected to be worked on, proceed in the following sequence:”
    a) Allow time for the capacitor charge to drain off partially.

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    b) Short-circuit the capacitor according to approved methods and apply a jumper.
    c) Ground the apparatus.

    F.14
    “The test operator must be the first person to place hands on the equipment following
    the test unless other approved procedures are being followed.”

CORRECTIVE ACTIONS:
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   TI Managers to review and modify the High Voltage Tests procedure of the Field
    Testing Manual with the department personnel section F 1 through 16. The
    modifications to include: Install jumper, which is to remain in place when the leads
    are not connected to a device to be tested. Other option would be to short out leads
    and then remove jumper, etc.
    Owner TI Managers                                  Due date Oct. 15, 2002.
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   Note: TI hires will be trained on this procedure in training that’s now being
          developed.
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   Review modified testing procedure with TIE’s
    Owner TI Managers                                Due date Oct. 15, 2002.
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   Set expectation that high voltage testing procedure will be reviewed with all parties
    involved in each fault locating assignment.
    Owner TI Managers                               Due date Oct. 15, 2002.
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       TI to make an inventory of #4 cu stranded jumpers (minimum) designed for shorting
        out hi-pot testing leads. These jumpers are available with every hi-pot-testing unit.

   Owner TI Managers                            Due date September 30, 2002
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CONTRIBUTING FACTORS:
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1. Job Brief procedure not followed: All parties involved with incident, although trained
   in job brief process, did not follow established process.
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BASIS:
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Individuals on job site were not aware of job briefing. Therefore, there was no job
continuity.
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F. 1 (c) “ All personnel concerned with the test are thoroughly briefed in the procedure
           to be followed, and that all signals between men of a team are thoroughly
           understood.”
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CORRECTIVE ACTIONS:
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        Construction superintendent to re-state expectations and importance of the job
         brief, and insure that forms are completed prior to the start of any job.
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        Testing procedure to be handed out and discussed during the job briefing @ each
         fault locating assignment with all parties involved.
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         All Regional Directors                   Due date October 7, 2002
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CONTRIBUTING FACTORS:
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2. Safety rulebook practice 410.08.7 was violated resulting in the proper PPE not used.
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            “Connect or disconnect test equipment to terminals or ends of cables normally
             energized at more than 600 volts to ground.
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BASIS:
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The individual was not wearing 20kV gloves while handling the Hi-Pot set test leads.
Therefore, the splicer sustained a DC electrical contact. The construction crew though
the hi-pot testing unit ground provided personal protection just as well as the system
personal protective grounds.
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  F. 15 – “Rubber gloves or other protective insulating goods shall be used wherever
           safety requires.”
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CORRECTIVE ACTIONS:
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        Review Safety Rule Book Section (410.08.7): To included while handling test leads,
         rubber gloves ( 20kv ) to be worn.
         Owner John Boyle                              Due date October 7, 2002
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        All Regional Directors                        Due date October 7, 2002


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CONTRIBUTING FACTORS:
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3. Three way communication inadequate.
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BASIS:
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The splicer did not use three-way communication while removing Hi-Pot set test lead. He
did not inform the TI engineer of his actions (disconnecting test leads from faulted
cable). A number of events in this incident indicate the lack of 3-way communication
such as job briefing (which would introduce the type of 3-way use by equipment
operator).
F. 1 (d) “Clearance is obtained from the operator in charge.”
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CORRECTIVE ACTIONS:
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       Review Three Way Communication and set clear expectations for the use of 3 Way
        Communication every time operating instructions are given and received.
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        Owner TI Managers                           Due date October 7, 2002
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CONTRIBUTING FACTORS:
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4. Misunderstanding of protective grounds
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BASIS:
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The crew and other involved personnel misunderstood the test leads from the hi-pot set
could be used as a safety ground. The grounding device for the Hipotronics only
grounds the unit and is not to be used for personal protections. No other safety
precautions were taken.
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CORRECTIVE ACTIONS:
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       TI Managers to educate Field Supervisor on High Voltage testing procedures.
        Owner TI Managers                           Due date October 7, 2002
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       Field Supervisors to educate crews on High Voltage testing procedures.
        Owner Regional Directors                    Due date October 7, 2002
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Procedures
__ No procedure established at time of incident
P Procedure not used
C Procedure followed incorrectly
__ Wrong or incorrect procedure used
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Training
__ No training provided to individual(s) involved in incident
__ Training was overdue for the individual(s) involved
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__ Training that was provided was less than adequate
C Individual(s) involved in the incident had an understanding less than adequate to
perform the task without incident
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Quality Control
__ No quality controls were established at the time of the incident
__ Quality control/inspection was not required
__ Quality control not performed
__ Quality control instructions need improvement
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Communications
__ Verbal communication was misunderstood
__ Written communication was misunderstood
__ There was no communication
C_ Communication was less than adequate
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Management System
__ Standards, policies and/or controls were less than adequate
__ Standards, policies and/or controls were not used
__ Oversight, evaluation, and/or audits for individuals involved were lacking
__ Corrective actions were less than adequate or not yet implemented
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Human Engineering
__ Human-machine interface difficulty
__ Work environment needed improvement/was adverse
__ System was overly complex, too many items were being monitored
__ Non-fault tolerant system, errors not detectable/recoverable
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Immediate Supervision
__ No preparation/briefing of crew
C_ Preparation/briefing was less than adequate
__ Selected worker was not qualified to perform the task
__ There was no supervision during the performance of the task
C Supervision during the performance of the task was less than adequate (by PIC)

Enter Cause codes in the Passport AR T/C panel



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Complete the RCI assignment in PassPort and email the completed RCI report to:
ComEd EAG. Assign Corrective Actions (not already completed) via PassPort.
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-----CAUSE CODE LIST-----
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Identify trend code(s) for the RCI report. Indicate “C” for each contributing cause and “P”
for the Primary root cause. Leave all non-causes blank.
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Procedures
__ No procedure established at time of incident
C_ Procedure not used

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__ Procedure followed incorrectly
__ Wrong or incorrect procedure used
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Training
__ No training provided to individual(s) involved in incident
__ Training was overdue for the individual(s) involved
__ Training that was provided was less than adequate
C_ Individual(s) involved in the incident had an understanding less than adequate to
perform the task without incident
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Quality Control
__ No quality controls were established at the time of the incident
__ Quality control/inspection was not required
__ Quality control not performed
__ Quality control instructions need improvement
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Communications
__ Verbal communication was misunderstood
__ Written communication was misunderstood
__ There was no communication
C_ Communication was less than adequate
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Management System
__ Standards, policies and/or controls were less than adequate
__ Standards, policies and/or controls were not used
__ Oversight, evaluation, and/or audits for individuals involved were lacking
__ Corrective actions were less than adequate or not yet implemented
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Human Engineering
__ Human-machine interface difficulty
__ Work environment needed improvement/was adverse
__ System was overly complex, too many items were being monitored
__ Non-fault tolerant system, errors not detectable/recoverable
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Immediate Supervision
__ No preparation/briefing of crew
__ Preparation/briefing was less than adequate
__ Selected worker was not qualified to perform the task
__ There was no supervision during the performance of the task
C_ Supervision during the performance of the task was less than adequate

Enter Cause codes in the Passport AR T/C panel




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