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Notice No.06-0054 Issued: 06.09.06OPG Records #08960.2424 T5 yy.mm.dd

IINNIITTIIAATTEEDDBBYY:: CCOORRPPOORRAATTEEGGRROOUUPPSS

HHYYDDRROOFFOOSSSSIILLNNUUCCLLEEAARR Initial Communication Summary of Investigation

Type of Event External Safety Incident

Title Location

Type of Event

Description

MRPH Rating

Fort Calhoun Nuclear Station, Omaha Public Power District, Omaha, Nebraska

Electrical Arc Flash

Utility electrician suffered second and third degree arc flash burns to the arms, face, and torso.

N/A

Date of Event August 26, 2006

Event Summary This external incident was identi fied through OPGs OPEX (Operating Experience)Program.

On Saturday August 26, 2006, at 0945 a.m. an OPPD Fort Calhoun Station electrician sufferedsecond and third degree flash burns to the arms, face, and torso.

The arc flash occurred when the electrician used a high voltage detection device (hot stick) in aspare 480 V breaker cubicle, which caused a phase-to-phase short resulting in the arc. Entry intothe 480 V cubicle was not part of the pre-planned job and approved work scope and was notdiscussed during the pre-job briefing. The electrician took this action without consulting with hiscrew leader, the other electrician assigned to this task, or anyone else. It is surmised that theelectrician decided to enter the 480 volt breaker cubicle to determine if the hot stick wasfunctioning properly.

The electrician did not don the required personal protective equipment for accessing the breakercubicle (Nomex suit, gloves, and face shield) as set out in the station safety manual.

Injuries/Damage Utility electrician suffered second and third degree flash burns to the arms, face, and torso.

Damage to the electrical cubicle and electrical components.

SAFETYFL A SH Re o r t


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Causes Unknown Apparent

Root

A full investigation into the exact causes and contributors is currently underway, but several keylearnings are evident:

This was a relatively routine task (live-dead-live voltage check), for the electrician [STAR Stop,Think, Act, Review]

A. There was a question about how the functionality of the voltage detection device (hotstick) could be tested. [Questioning Attitude and Conservative Decision Making].

B. The electrician was in a spare 480 V breaker cubicle that was outside the original workscope and procedure for the task he was performing. [Our Human Performance Tools

of: Procedure Use, Peer Checking and Questioning Attitude]C. The proper PPE for being in a 480 V breaker cubicle was not utilized. [Procedural

Compliance]

Actions Taken The employee was transported via helicopter to the Creighton University Hospital and then to theSaint Elizabeth Burn Center in Lincoln, NE. Electrician remains in hospital.

Stand Down to review the incident conducted within the utility.

OPEX Flash Report initiated within OPG.

Recommended

Action fo r Others

Communicate this event to staff within OPG who perform electrical work to reinforceexpectations, including:

Procedural compliance Questioning Attitude, Conservative Decision Making, STAR, Peer Checking Safety procedures for performing electrical work including protection from electrical arc

flash incidents

Below is Summary of Key Learnings as published at Fort Calhoun following the incident:

A. Performing a live-dead-live voltage check is an everyday routine task forelectricians. In this case, however, the method that the electrician chose to use toperform the task was NOT routine. Appropriate planning, preparation, and safetyrequirements were not followed. [Guard against complacency]

1. Tasks that seem routine are not routine when they are performed in a manneror method that are outside of our normal procedures or process controls. Whena task cannot be performed according to approved procedures and processes,let your supervisor know and get the issue resolved before you proceed. Makeit a point to ensure you have the appropriate training or oversight so the taskcan be done safely.

2. Even the most routine tasks can cause problems if we are not engaged whenwe perform it. Guard against complacency by paying close attention to the taskand rigorously following the procedure.

B. There was a question about the functionality of the current testing device (hot stick).[Dont answer your own question].

1. When questions arise about on-going work STOP and get the right peopleinvolved to get the question addressed BEFORE proceeding. By doing this webring to bear the collective experience of the team to solve the problem ratherthan the person who discovered or is struggling with it. Your first and primarypoint of contact is your supervisor. Other people to contact include the One-Stop-Shop, Work Week Manager (on-line), or Shift Outage Manager (Outage).

C. The electrician entered a spare 480 V breaker cubicle that was outside the originalwork scope and procedure for the task he was performing. [Our HumanPerformance Tools of: Procedure Use, Peer Checking and Questioning Attitude]

1. If you find yourself in a situation not covered by the procedure or workdocument, the right thing to do is STOP and contact your supervisor BEFOREproceeding. Your supervisor will help determine if a change to the procedure orwork document is needed prior to proceeding OR if another procedure applies.

2. If you are unsure if the procedure or work document applies for your task, get aPEER CHECK from an experienced co-worker. This helps prevent gettingoutside your scope and procedural bounds.


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3. If you find yourself Distracted, Uncomfortable, or Confused (DUCs), then STOPand verify that you are still within the bounds of the procedure or workdocument. If you are still not certain, contact your supervisor and get thenecessary changes made BEFORE proceeding.

D. The Electrician did not wear the proper PPE for being in a 480 V breaker cubicle.[Our key platform of Being Deliberate (with our actions under control) and Followingthe Rules].

1. FCSG-15; FCS Safety Manual has specific requirements on the use of PersonalProtective Equipment (PPE) that must be properly worn during work in the

plant. Use of the equipment is MANDATORY. By being deliberate andfollowing the rules with PPE we help ensure our safety and the safety of others.

ManagementContact:

PhoneNumber

Contact

SafetyContact:

Greg JacksonPhoneNumber

(905) 839-1151 x8501

IMS No./SCR No. N/A

For Site Use Only

Local Site

Disposition94343 Rev 06-04

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