On October 3, 2001, at the Brookhaven National Laboratory (BNL), a worker used a high-voltage hotstick to open three fused cutouts in a 2,300-volt Westinghouse switchgear cabinet without authorization to do so, without checking for voltage, and without wearing personal protective equipment (PPE). Workers were preparing to replace an induction regulator located in Building 901 (Cyclotron). The line side of the fused cutouts was energized, but there was no load on the circuit. There were no injuries. However, because of the potential for serious personnel injury, the facility manager reported this occurrence as a near miss. A final report was filed on January 29, 2002, which provides additional information and insight into the incident. (ORPS Report CH-BH-BNL-BNL-2001-0026). In preparation for the induction regulator replacement, towerline workers were sent to inspect the Westinghouse switchgear cabinet (Figure 1). During this inspection a Chemistry Department worker, who was not part of the inspection team, opened the fused cutouts on his own initiative to facilitate the inspection. This individual followed verbal procedures he had been given earlier by a now-retired cyclotron operator, who had informed him that opening contacts in the power circuit de-energized the fuses. Believing the circuit was de-energized, the worker did not check for voltage and was not wearing appropriate PPE. The towerline workers and the BNL supervisor who were in an adjacent room and who witnessed only the opening of the third fused cutout explained the seriousness of the work activity and the need to use proper PPE to the BNL worker and to his supervisor. The towerline workers notified their supervisor and the Plant Engineering Environmental Safety and Health Coordinator. In the course of the inspection, the towerline workers addressed additional equipment issues related to the transformer room. These issues involved a missing view port in a switchgear cabinet, out-of-date labels, and inadequate space for the switchgear cabinets. As a result of this inspection, the Laboratory Electrical Safety Officer locked out the 2,300-volt Westinghouse switchgear cabinet equipment. The direct cause of the incident was that the worker performed hazardous work without adequate work planning and control. The worker failed to recognize that the activity required a pre-job hazard review and formal authorization, and opened the fused cutouts on his own initiative.

The worker's supervisor failed to ensure that the worker had been properly trained in this activity, and that any verbal instructions needed to be reviewed and proceduralized. The following are some corrective actions that have been implemented as a result of this event.

• Facility management reviewed this incident with personnel in the departments and groups involved with cyclotron operations to emphasize the necessity of proceduralized work planning before carrying out any verbal procedures, as well as the need to review procedures associated with legacy facilities.

• Chemistry Department personnel received a memo emphasizing the necessity of reviewing work practices associated with legacy equipment to ensure worker safety, and that work cannot be carried out without proper work planning.

• Maintenance personnel replaced the glass that was missing from the view port on the rectifier cabinet before the circuit was re-energized.

This occurrence illustrates the inadequacy of verbal procedures, particularly those involving infrequently used equipment. Procedures need to be formally documented to ensure that work can be performed safely. Management needs to emphasize to workers that work cannot be carried out without formal authorization, appropriate procedures, and task-specific controls in place. In addition, management needs to ensure that legacy equipment is inspected before it is used, and, wherever appropriate, brought up to current codes. See Photos at http://tis.eh.doe.gov/oeaf/
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