Complacency is Your Enemy: Anatomy of an ARC Flash Incident and Lessons Learned

• Published in: IEEE transactions on industry applications Vol. 57; no. 1; pp. 1122 - 1128
• Main Authors: Martinez, Tommy R., Trujillo, Julian K.
• Format: Journal Article
• Language: English
• Published: New York IEEE 01.01.2021; The Institute of Electrical and Electronics Engineers, Inc. (IEEE)
• Subjects: Arc discharges; Breakdown; Buildings; Circuit breakers; Cleaning; Electrical arc flash; electrical injury; electrical risk assessment; electrical safety; Flashover; Hazards; Human error; human performance; Maintenance engineering; Monitoring; Preventive maintenance; Risk analysis; Risk management; Substations; Switchgear
• DOI: 10.1109/TIA.2020.3038138
• ISSN: 0093-9994

On May 3, 2015, a serious electrical incident occurred at one of the Department of Energy's national laboratories. Preventative maintenance was being performed on 13.8-kV switchgear, which included the task of cleaning individual switchgear cubicles. A wireman unknowingly entered an energized cubicle in order to clean it with a commercial spray cleaner. When he proceeded to spray the cleaner onto the energized components, he suffered severe injuries from the resulting arc flash and blast. This article will breakdown the discussions, thought processes, and planning decisions that were made from both the facility and worker's perspective. It will describe risk factors that increased the likelihood of this incident and breakdown how the addition of a single risk control measure could have prevented this incident. Finally, it will describe the details leading up to the incident, the incident itself, the response, and lessons learned. The lessons learned associated with this incident emphasizes the importance of using tools to promote active thinking during both the planning and execution of the work in order to reduce the likelihood of human errors associated with complacency.