Lessons learned: Serious near miss incident involving electric shock

The incident

An engineer suffered a minor electrical shock while troubleshooting a faulty 690V electric motor. The engineer checked the drive belt and then proceeded to measure the phases. Measuring the phases was not in his initial plan when he prepared the troubleshooting. The incident occurred when he was measuring the phases.

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The electric motor junction box cover was removed, and access to the  wiring was good. Measurement was carried out using a multimeter. When he was about to replace the cover of the junction box, it touched one of the three phases and he suffered a minor electrical shock in his fingers. He was uninjured but had himself checked by the medic who confirmed this.

Probable cause

• Failure to manage change: the engineer moved from doing a task which did not require PTW and LOTO, to a task that did. Had he stopped the job and correctly assessed the risk, it is likely that safety barriers would have been in place and risks mitigated;
• Energy Isolation: he did not identify the energy source and did not isolate it when the cover to the connection box was taken off and on. This resulted in him working on live equipment without proper PPE;
• Work Authorization: he did not identify that a Permit to Work was required before measurement of the phases. In addition, this task was not a part of the original plan and was not discussed with anyone.
• The engineer decided on his own, without discussing with anyone else, to proceed and measure the phases on a live electric motor without a Permit to Work nor Lock Out/Tag Out in place;
• He was wearing safety/rubber boots, coverall and safety glasses but not approved gloves.

Lessons learned

• This incident happened when routine work was being carried out. Work that was initially low risk, became a high risk task when the engineer included troubleshooting/measuring phases on the electrical motor. He did not carry out a thorough risk assessment of the situation and did not complete required documents;
• Whist we all want to solve the problem and get the job done, we should never jeopardize our own health or safety by ignoring precautions set by our company’s policies, procedures and checklists;