1. Incident review December 13 & 14, 2016
10/18/2016 induced voltage near miss.
11/16/2016 CT cabinet incident.
12/2/2016 energized cable cut.
Today we are here to cover three important incident that have happened over the last month and a half.

2. 10-18-2016: Cutting in new Transformer for apartments near Bethany homes
Switching order was initiated and implemented
Tie M1 & M2 at C-289.
VFI’s set to 200 AMP, hot line tag on.
Isolated A&B phase at C-289.
Isolate C phase at C-900.
Isolated three phases C-693.
Transformer at 955 was not mapped

3. Near Miss 103-22C What Happened
Tested voltage at 693 for de-energized cable and it had up to 4000 volts
Retested with chance sticks still getting reading.
Grounded, no snap, retested still had voltage.
Checked IPAD didn’t find any proposed job (Update IPADS, proposed 1- 4).
Found transformer had been installed that was not in mapping. (955)
Crews had switched out line and went to test voltage
Explain proposed 1,2,3,4 jobs in mapping

4. PREVENTION & follow-up
Once transformer is set and transformer report sent to group, transformer will be added to maps as long as proposal is on map.
If needed we will go back and correct once WO is complete
New transformers are getting added. Project posted as on staking sheet.
Still working on getting everything mapped.
Line crews and D/C’s need to refer any changes to the staking sheet to GIS IMMEDIATELY!!!!
What area’s still need attention for mapping

5. Near Miss C
Questions
Comments
Concerns

6. Brooks Harbor School CT Cabinet 103-19A-774 What Happened
Checking phase rotation in CT cabinet.
Employee #1 holding meter and one lead on buss work.
Employee #2 holding one lead on buss work.
Employee #2 moved to put on second lead when the first lead slipped and made contact between phase and ground.
3 cal arc flash (calculated)
VFI opened .68 seconds
All three phases arced to cabinet
Arc flash temperatures caused nail head to vaporizes which caused rapid expansion as it changed from a solid to vapor resulting in explosive pressure and sound.
Wind blowing possibly moved gas and main arc away from crew.

7. Meter lead went into hole in buss work and contacted grounded buss work support

8. CT Cabinet 103-19A-774 Analysis
Nails taped to alligator clips.
Vaporized nail added to incident?
Required PPE worn.
Area cleared of non-CCEC personnel
Wind pushed gases to far side.

13. CT Cabinet 103-19A-774 prevention
NO modified tools…
Nails taped to ends of alligator clips
Cover-up
Face Shields
Purchase new leads/meters.
Fluke
GreenLee
Do we need cover-up or dividers
Who has what, I have only heard from Lisbon.

14. CT Cabinet 103-19A-774 follow-up
Review arc flash rules.
Add ear plugs
Face shield
Change procedures.
What hidden hazards do we have out. there
Field Modification.
Letter to contractors.
Jodi and Troy to review Arc flash rules
Clip shall be used in cabinets, probes used only used with utilicos
What are you running into out there
No field modification unless approved by manager of safety
Mike will work with marketing on Watt’s Happening newsletter give us room and also hazards of OH lines.

15. CT Cabinet 103-19A-774 Incident
Questions
Comments
Concerns

16. Energized cable cut JL BEERS 103-27B-7600
Switching to isolate cable to cut in new service for Casey’s General Store.
Power Control get permission from MPC to tie Moderow #1 and #2.
Set regulators on Moderow #1 and Moderow #2 at close to same step.
Set VFI’s set to 200 amps.
Hot line tag on.
PPE worn.
Switching order
Set VFI on tap going east in switch S075 to 200 amps
Set VFI on tap going south/west in switch S010 to 200 amps

17. Energized cable cut 103-27B-7600
Close in open in transformer
Open going east in transformer (the two-way insert for the Verizon tower is on the east/south run and will not be affected by this switching).
Open going north/west in transformer (the radial to JL Beers should be off of a two-way insert with the south elbows and will not create an outage for JL Beers).

18. Energized cable cut 103-27B-7600
Contractor dug-up cable.
Employee got in pit cut cable.
Large Arc flash.

19. Correct Incorrect current

21. Main issues
The locates were not correct despite having it located both by company and contract employees.  The issue may have been caused from multiple runs from the transformer tracer wires bonding together in one cutout box.  There was also abandoned cable in the area.
The mapping in the area was updated based on the locates.
Testing methods for determining energized cables are not accurate due to the physical properties of jacketed cable with a concentric neutral and a semicon shield around the conductor.

24. Prevention & follow-up
Hot Line tag was active and minimized the worker exposure.  This is a good reminder to have Power Control set hot line tag whenever working on a line even if it is de- energized.
PPE was worn, including rubber gloves.
The mapping will be corrected for the area, along with the staking sheet.
Future issues found during locating will be brought to GIS’s attention and will be investigated prior to posting.
Operations will review using more the one tracer box for multiple runs in pad mounted switches and transformers .

25. Prevention & follow-up
Engineering & Operations will review using GPS when installing URD cable and the effect on locating.
Operations will utilize an approved spiking tool and remote cable cutters on all loop fed underground cable.  This would not of prevented an outage nor the flashover event.  It would have increased the distance to the fault.
Safety will investigate testing methods for underground cable.
Tagging?
Mapping two-ways?

26. Is this how everyone is labeling their tags

27. Energized cable cut 103-27B-7600
Questions
Comments
Concerns

29. Incident improvements
Timeliness for incident, near miss, injury report.
Employee OP502J1 no later than next business day notify/report
Supervisor report
Review Manager of Safety/Staff
Safety alert.
Investigation.
Follow-up.
OP502J1 In the event of an accident or injury, employees shall notify the Manager of Safety as soon as possible, but no later than before the end of the next business day. If the Manager of Safety is unavailable, employees shall notify their immediate supervisor who shall in turn contact a staff member.
Safety alert – sent out within 24 hours? Short description of events to notify all, more information after investigation
Instigation –
Review at next safety meeting – 2017 spread class room meetings across the year, have short video conferences once or twice a month.
Follow-up – thirty days after major event see how things are going.

30. Incident Review
Questions
Comments
Concerns