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NASA-LLIS-1378
Lessons Learned – Implementation and Verification of Lockout/Tagout Procedures
Year: 2002
Abstract: Abstract:
The company's failure to implement and enforce their company safety program, as defined in their Safety & Health plan submitted to NASA, resulted in a lax safety culture. This lax safety culture supported the deceased, a journeyman electrician, in feeling comfortable working on an energized electrical circuit without the proper PPE (personal protective equipment), which he ultimately contacted resulting in his electrocution. Specifically, procedures were not followed when the deceased and his apprentice did not stop work and isolate the circuit or seek a "hot work permit" upon discovering the circuit was still energized.
The subsequent investigation revealed three central themes involved in the mishap:
1. Implementation and Verification of Lockout / Tagout Procedures,
2. Accurate Drawings of Facility Systems as a Prerequisite to Project Implementation, and
3. Demand and Ensure High-Quality Safety Performance from all Contractors (the subject of this lesson).
Each theme is published as a separate lesson. (A fourth lesson underscores the successful implementation of the preliminary investigation, which was critical to performing a successful, formal mishap investigation.)
The company's failure to implement and enforce their company safety program, as defined in their Safety & Health plan submitted to NASA, resulted in a lax safety culture. This lax safety culture supported the deceased, a journeyman electrician, in feeling comfortable working on an energized electrical circuit without the proper PPE (personal protective equipment), which he ultimately contacted resulting in his electrocution. Specifically, procedures were not followed when the deceased and his apprentice did not stop work and isolate the circuit or seek a "hot work permit" upon discovering the circuit was still energized.
The subsequent investigation revealed three central themes involved in the mishap:
1. Implementation and Verification of Lockout / Tagout Procedures,
2. Accurate Drawings of Facility Systems as a Prerequisite to Project Implementation, and
3. Demand and Ensure High-Quality Safety Performance from all Contractors (the subject of this lesson).
Each theme is published as a separate lesson. (A fourth lesson underscores the successful implementation of the preliminary investigation, which was critical to performing a successful, formal mishap investigation.)
Subject: Energy
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| contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
| date accessioned | 2017-09-04T18:42:06Z | |
| date available | 2017-09-04T18:42:06Z | |
| date copyright | 08/29/2002 | |
| date issued | 2002 | |
| identifier other | JYVEQCAAAAAAAAAA.pdf | |
| identifier uri | http://yse.yabesh.ir/std;query=authoCA5893FD081D49A96159DD6EFDEC014A/handle/yse/223644 | |
| description abstract | Abstract: The company's failure to implement and enforce their company safety program, as defined in their Safety & Health plan submitted to NASA, resulted in a lax safety culture. This lax safety culture supported the deceased, a journeyman electrician, in feeling comfortable working on an energized electrical circuit without the proper PPE (personal protective equipment), which he ultimately contacted resulting in his electrocution. Specifically, procedures were not followed when the deceased and his apprentice did not stop work and isolate the circuit or seek a "hot work permit" upon discovering the circuit was still energized. The subsequent investigation revealed three central themes involved in the mishap: 1. Implementation and Verification of Lockout / Tagout Procedures, 2. Accurate Drawings of Facility Systems as a Prerequisite to Project Implementation, and 3. Demand and Ensure High-Quality Safety Performance from all Contractors (the subject of this lesson). Each theme is published as a separate lesson. (A fourth lesson underscores the successful implementation of the preliminary investigation, which was critical to performing a successful, formal mishap investigation.) | |
| language | English | |
| title | NASA-LLIS-1378 | num |
| title | Lessons Learned – Implementation and Verification of Lockout/Tagout Procedures | en |
| type | standard | |
| page | 4 | |
| status | Active | |
| tree | NASA - National Aeronautics and Space Administration (NASA):;2002 | |
| contenttype | fulltext | |
| subject keywords | Energy | |
| subject keywords | Facilities | |
| subject keywords | Human Factors | |
| subject keywords | Human Resources & Education | |
| subject keywords | Independent Verification and Validation | |
| subject keywords | Industrial Operations | |
| subject keywords | Personal Protective Equipment | |
| subject keywords | Policy & Planning | |
| subject keywords | Procurement Small Business & Industrial Relations | |
| subject keywords | Program and Project Management | |
| subject keywords | Risk Management/Assessment | |
| subject keywords | Safety & Mission Assurance | |
| subject keywords | Test & Verification |