Text taken from various Lessons Learned documents:
a) Employees should limit access to damaged equipment and immediately inform proper individuals (i.e., supervision), whenever they discover a piece of equipment that could possibly injure/harm someone, if they were to come near or in contact with it. Employees should never attempt to fix equipment that they have no training or qualifications to fix. Even qualified employees should not attempt to fix equipment until all hazards have been completely identified and mitigated.
b) Basic work control concepts apply to all work regardless of the performer. The Job Safety Analysis (JSA) for the project indicated that such work required either a lockout/tagout or an Energized Work Permit. Work on electrical components requires either a lockout/tagout or extraordinary work controls specified in an approved work package.
c)Verbal instructions are inappropriate especially when involving potentially serious hazards and unfamiliar work. They need to be written as formal procedures to ensure compliance with the tenets of Integrated Safety Management (ISM).
Management needs to emphasize to workers that work that falls outside of skill-of-the-craft for their level of training and expertise cannot be carried out without having formal procedures and/or task-specific controls in place.
A memorandum was distributed to [unnamed] Department personnel emphasizing the necessity of reviewing work practices associated with equipment to ensure the procedures are in compliance with ISM (Integrated Safety Mgmt*) standards before use of these procedures and that work cannot be carried out without involving work planning, even with the best of intentions.
d) Personnel must clearly understand who the “Person in Charge” (PIC) is before, during, and after work activities. The PIC needs to be readily available to monitor work progress, to ensure maintenance activities are conducted according to facility policies and procedures, and that proper turnover is performed to maintain personnel safety. (see note a) about who should perform work - the trained person or the top dog with the authority...?)
In addition, the PIC was not clearly identified or was not trained to do the work. The initial PIC failed to provide effective oversight of the job and did not effectively turn over to a replacement PIC.
e) Lockout/Tagout needs to be performed as early as possible in the sequence of work. Established procedures must be followed to mitigate the hazard even if the worker does not perceive the hazard as justifying the effort needed to mitigate it. When replacing faulty or suspect components, the replaced item should be marked or otherwise segregated from new items to avoid reuse of the faulty or suspect item.
Ensure workers read and understand lockout/tagout procedures, including that they should never do such work alone, especially during off-work hours. Require that personnel invoke a stop work when it appears that an electrical worker is going to work on energized circuits. Conduct a pre-job briefing to identify potential safety risks, to review requisite procedures, and to ensure that timing is not the primary consideration for an activity. Assure that replaced components are identified and isolated from new components to prevent any mix-ups.
f) A highly disciplined approach is necessary to maintain the rigor and attention to detail required by the Lock and Tag program. Management should periodically communicate their expectations concerning the lock and tag program to facility personnel. These expectations should stress the importance of exercising a high level of attention to detail when installing and verifying locks and tags and should emphasize the importance of a sound lock and tag program to ensure the safety of personnel. Everyone involved in the lock and tag process must follow the process rigorously. They should also be held accountable for inadequate performance since safety is at stake.
g) Energized work should only be performed when absolutely necessary. In addition, when circuits are checked for power, the check should be thorough, including several points to ensure all power sources are identified.
(same incident further qualifies who should do the work: Energized electrical work should be performed when absolutely necessary, by a qualified electrician. When circuits are checked for power, the check should be thorough, including several points to ensure all power sources are identified.)
There also appears to be some information in the IEEE Buff Book regarding protection and coordination: http://standards.ieee.org/colorbooks/sampler/Buffbook.pdf
* ISM =
Develop / Implement Controls (for Safety)
Define Work (with attention to Safety issues)
Perform Work (Safely)