Equipment found live: drawings incorrect for Lock-out/Tag-out

What happened?

An electrical working foreman was “checking for dead” on control oil pump motor space heaters. It was discovered that the heaters were still live and energized. The heaters were not included in the Lock-out / Tag-out arrangements. After review of the drawings and the load centre breaker schedule, it was determined that the drawing and the breaker schedule were incorrect. The heaters were indicated as one circuit on the drawings and the breaker schedule, but they were traced back to another circuit.

Work was stopped and the LOTO, drawings and breaker schedule were all modified.

What went right

• An increased focus on LOTO during this outage allowed electrical personnel to find the error;
• The electrical working foreman noticed the hazard and it was corrected;
• No-one was harmed.

What went wrong?

• The drawings were incorrect, but as this work was infrequent, it had not been noted previously;

Lessons learned

• There was a review of work practices with plant staff to communicate the issue as a result of this alert;
• Ensure all appropriate or possibly relevant electrical equipment is locked out/tagged out;
• Always “check for dead”.

Members may wish to refer to:

• Electrician suffered flash burn to hand
• Crisis Management: Rail Industry High Potential Near Miss
• Incorrect as-built drawing configuration
• Incorrect pressure gauge on high pressure supply line