Electrical Junction Box Damaged by Clamp Truck
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1 Electrical Junction Box Damaged by Clamp Truck Purpose To share lessons learned gained from incident investigations through a small group discussion method format. To understand lessons learned through a Systems of Safety viewpoint. This material was produced by the Labor Institute and the United Steelworkers International Union under grant number SH F-42 Susan Harwood Training Grant Program, for the Occupational Safety and Health Administration, U.S. Department of Labor. It does not necessarily reflect the views or policies of the U.S. Department of Labor, nor does mention of trade names, commercial products or organizations imply endorsement by the U. S. Government. Volume 08, Issue The Labor Institute 1
2 Electrical Junction Box Damaged by Clamp Truck Background Information Before beginning this, please review this and the next page which contain information that will introduce the concepts of and Systems of Safety. Creating a safe and healthy workplace requires a never ending search for hazards that sometimes are not obvious to us. These hazards exist in every workplace and can be found by using various methods. are just as the name suggests: learning from incidents to prevent the same or similar incidents from happening again. Systems Are Not Created Equal: Not equal in protection and not equal in prevention. Using our Systems Focus to uncover system flaws or root causes is only one part of controlling hazards. We also need to look at the systems involved to decide on the best way to deal with the problem. The most effective way to control a hazard is close to its source. The least effective is usually at the level of the person being exposed. The system of safety in which the flaw is identified is not necessarily the system in which you would attempt to correct the flaw. 2
3 Electrical Junction Box Damaged by Clamp Truck Major Safety System Level of Prevention Design & Engineering Highest the first line of defense Maintenance & Inspection Mitigation Devices Warning Devices Middle the second line of defense Training & Procedures Personal Protective Factors Lowest the last line of defense Effectiveness Most Effective Least Effective Goal To eliminate hazards To further minimize and control hazards EXAMPLES OF SAFETY SUB- SYSTEMS** Technical Design and Engineering of Equipment, Processes and Software Management of Change (MOC)** Chemical Selection and Substitution Safe Siting Work Environment HF Organizational (must address a root cause) Staffing HF Skills and Qualifications HF Inspection and Testing Maintenance Quality Control Turnarounds and Overhauls Mechanical Integrity Enclosures, Barriers Dikes and Containment Relief and Check Valves Shutdown and Isolation Devices Fire and Chemical Suppression Devices Machine Guarding Monitors Process Alarms Facility Alarms Community Alarms Emergency Notification Systems Operating Manuals and Procedures Process Safety Information Process, Job and Other Types of Hazard Assessment and Analysis Permit Programs Emergency Preparedness and Response Training Refresher Training Information Resources Communications Investigations and To protect when higher level systems fail Personal Decisionmaking and Actions HF Personal Protective Equipment and Devices HF Stop Work Authority Management of Personnel Change (MOPC) Work Organization and Scheduling HF Work Load Maintenance Procedures Pre-Startup Safety Review Allocation of Resources Buddy System Codes, Standards, and Policies** HF - Indicates that this subsystem is often included in a category called Human Factors. * There may be additional subsystems that are not included in this chart. Also, in the workplace many subsystems are interrelated. It may not always be clear that an issue belongs to one subsystem rather than another. ** The Codes, Standards and Policies and Management of Change subsystems listed here are related to Design and Engineering. These subsystems may also be relevant to other systems; for example, Mitigation Devices. When these subsystems relate to systems other than Design and Engineering, they should be considered as part of those other systems, not Design and Engineering. Revised October
4 Electrical Junction Box Damaged by Clamp Truck Title: Electrical Junction Box Damaged by Clamp Truck Identifier: Volume 08, Issue 46 Date Issued: December 28, 2008 Statement: In this particular, you will be able to see how using a Systems of Safety approach can prevent property damage. The damage to property would have been prevented if the electrical junction box had been installed in an area where truckers were not moving and storing rolls of paper, or by utilizing a pathway. This would be proper use of the Design and Engineering System of Safety, Applying the Mitigation Devices System of Safety to keep clamp trucks away from the electrical junction box would have also prevented this property damage from occurring. Communicating to clamp truck operators to place their short clamp along walls when storing or moving rolls of paper would use the Training and Procedures System of Safety. Any of the above fixes, which utilize Systems of Safety, would have prevented property damage; but utilizing the highest level of the Design and Engineering System of Safety would be the best line of defense. 4
5 Electrical Junction Box Damaged by Clamp Truck Discussion: A worker in the shipping area was attempting to move some rolls of paper that were stored along the north wall of the shipping warehouse. There is an electrical junction box on the north wall where rolls of paper are being stored. There are also other electrical junction boxes and outlets (Fig. 10-2) along the north wall that have been damaged in the past. The worker could not see the electrical junction box hidden behind the rolls of paper stored along the north wall. There is nothing to protect the electrical junction box from getting hit by clamp trucks and rolls of paper. The clamp truck the worker was using consists of a clamp that has a short arm and a long arm (Fig. 10-1). The truck operator approached the pile of rolls with the long arm of the clamp facing the north side of the wall. As he took hold of a roll of paper, he heard a strange noise and immediately stopped his truck. The operator proceeded to investigate what had caused the noise. Upon seeing the damage to the electrical junction box, he realized that the long clamp of his truck had hooked onto the junction box and had damaged it. The worker immediately reported the incident to his supervisor. 5
6 Electrical Junction Box Damaged by Clamp Truck Fig Short and long clamp of a clamp truck. Fig Electrical junction boxes and outlets. 6
7 Electrical Junction Box Damaged by Clamp Truck Analysis The Logic Tree is a pictorial representation of a logical process that maps an incident from its occurrence, the event, to facts of the incident and the incident s root causes. Event Electrical junction box was damaged Clamp contacted junction box Worker was moving rolls of paper North wall used as roll storage area Electrical box has no barricade Long clamp was facing north wall Electrical junction box on north wall No SOS Failure SOS Failure Design and Engineering SOS Failure Mitigation SOS Failure Training and Procedures SOS Failure Design and Engineering 7
8 Electrical Junction Box Damaged by Clamp Truck Recommended Actions 1. Relocate junction box outside of storage area. 2. Install mitigation device to protect electrical junction box. 3. Communicate to truck operators to place the short clamp of their truck along the wall when moving or storing rolls of paper. 4. Redesign storage area to allow clearance room between walls and the rolls of paper. 8
9 Electrical Junction Box Damaged by Clamp Truck Education Exercise Working in your groups and using the Statement, Discussion, Analysis and Recommended Actions, answer the two questions below. Your facilitator will give each group an opportunity to share answers with the large group. 1. Give examples of ways to apply the Statement at your workplace. 2. Of the examples you generated from Question 1, which will you pursue in your workplace? (Note: When we say something you may pursue, we mean a joint labor-management activity or a union activity rather than an activity carried out by you as an individual.) 9
10 Electrical Junction Box Damaged by Clamp Truck Trainer s Success Inventory Following a (LL) session, the trainer who led the LL should complete this form. This information will: 1) Help you reflect on the successes and challenges of the session; 2) Help USW with new curriculum development; and 3) Help USW as a whole better understand how the LL Program is supporting their workers. By reviewing LL from different sites or from other areas of their workplaces, workers are able to analyze the information and apply these lessons to their own workplaces in order to make their workplaces healthier and safer. 1. Site name (if there are participants from more than one site, please list all). 2. Date of LL training 3. LL number used in today s Training 4. Your name 5. Summary of Education Question 1: Please summarize participants examples of ways to apply this LL Statement to their workplace. 10
11 Electrical Junction Box Damaged by Clamp Truck 6. Summary of Education Question 2: Please summarize actions or recommendations participants discussed pursuing at their workplace(s). Thank you for completing this form. 11
12 Electrical Junction Box Damaged by Clamp Truck EVALUATION : Electrical Junction Box Damaged by Clamp Truck Please answer the two questions below: 1. How important is this lessons learned to you and your workplace? (Circle one.) Rate on a scale of 1 to 5, with 5 being the most important What suggestions would you make to improve this? 12
13 Electrical Junction Box Damaged by Clamp Truck End of Training Trainer s Instructions Please complete the information below. Trainer s Name (Please Print) Date of training: No. of Participants: Total Hourly Management Location of Training: USW Local # Send: 1. This page; 2. The Education Exercise (page 9); 3. The Trainer s LL Success Inventory form (pages 10 and 11); 4. The evaluation for each participant (page 12); and 5. The Sign-in sheet (page 14) to: If you are a TOP Site (excluding DOE TOP Sites) All other sites (including DOE TOP Sites) Send to: Steve Cable 2915 Gradient Drive St. Louis, MO Send to: Doug Stephens United Steelworkers 3340 Perimeter Hill Drive Nashville, TN Thank you for facilitating the sharing of this Lesson Learned with your coworkers
14 Electrical Junction Box Damaged by Clamp Truck Sign-in Sheet Name of Class Date of Class Instructors: Please Check One* H M Print Name Signature *H = Hourly Worker M = Management or Salaried Worker 14
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