WORKER DISCHARGES CAPACITIVE BUILD-UP ON DEENERGIZED 13.

8 kV LINE

Copyright Material IEEE

Paper No. ESW2017-18

Wes Mozley
Wesley Enterprises
P. O.Box 3748
Albuquerque, NM 87190
USA
wesleyent@usinternet.com

Abstract - While performing a maintenance repair procedure
on a 13.8kV switch, an electrical worker omitted several safety
steps in the procedure. An accidental contact with the
deenergized line, coupled with the omission of these critical
safety steps, resulted in the worker discharging the capacitive
build-up on the line sustaining a significant electrical shock and
putting the worker's heart into fibrillation . The worker's failure to
seek medical treatment in accordance with company policy
nearly resulted in his death. This paper describes the
circumstances surrounding the electrical exposure and
discusses the lessons learned from the event
department had been run by operations personnel but a
decision had recently been made to assign an experienced
maintenance supervisor to the site.
Prior to the arrival of the new maintenance supervisor, the
use of voltage-rated gloves and grounding clusters was not in
practice at this particular site. The supervisor provided newly
tested gloves and leathers for each of the individuals and
educated them on the proper procedures for testing them prior
to wear. Further instruction was provided on the requirements
for maintenance and storage of the gloves, as well as the
requirements for periodic testing and the program that had
been put into place for the periodic testing .

Index Terms - assess risks, job briefing, shock, voltage- The electricians were also instructed in the use of grounding
rated gloves, electrical hazards, awareness and self-discipline clusters and the reasons for their use and over an hour was
spent practicing installing and removing the grounding clusters.

INTRODUCTION The Event

The best intentions of a safety program and the best written
procedures are of no use if they are disregarded in the field .
This paper discusses an event that nearly lead to the death of a
worker. It discusses the concepts of 'awareness and self-
discipline' as well as the company's role in changing the
electrical safety culture to insure the development of self-
discipline.
THE INCIDENT
Background
A 280 square mile remote testing site is fed by is fed by two
13.8 kV radial lines, one running along the eastern boundary
and the other running along the western boundary of the site. A
switch on the 13 mile long western line was in need of repair.
The job was scoped, risks were assessed, and a step-by-step
repair procedure was developed and reviewed at several levels
by electrical workers, a supervisor and high-voltage electrical
engineers. A job briefing was held with the two electricians
doing the activity level work with both electricians and the
supervisor reviewing and signing off on every step of the
procedure. Since the outage to perform the work would take
down half the site, the work was scheduled for 5 P . M., after
the workforce had left for the day.
The site had recently undergone a management restructuring
in the maintenance area. Previously, the maintenance
The electricians arrived at the site and decided between
themselves who would go up in the one-man bucket and who
would remain on the ground. The worker who was to remain on
the ground had the procedure in hand was calling out the steps
in the procedure, checking them off as they went.
The primary switch was opened and visual verification was
made that all three blades were open effectively isolating the
line from the power source. The ground electrician applied his
lockoutltagout device to the switch and locked it out. The aerial
worker refused to apply his lock, stating he thought it was
foolish to have to go through the lockoutltagout process when
the switch was in-sight. He further argued that the one lock on
the switch was enough. The aerial worker climbed in the
bucket and ascended to the repair point and began to work on
the mechanical linkage needing repair.
Specifically called out in the procedure was the donning of
voltage rated gloves prior to installation of the grounding
cluster. The ground worker repeatedly advised the aerial
worker to put on his gloves and the aerial worker repeatedly
declined, stating, "No need." A heated discussion ensued with
the ground worker maintaining that they needed to follow the
steps they both had signed off on in the procedure and the
aerial worker explaining that the new supervisor was
oversensitive about safety and didn't understand the level of
dexterity lost when one was wearing Class 2 rated gloves.
Pointing out the ground worker that he had over thirty years of
experience which was a good fifteen years more than the

978-1-5090-5099-4/17/$31.00 ©20 17 IEEE

1
ground worker or the new supervisor and that using voltage-
rated gloves was the latest safety flavor-of-the-month fad, he
continued to work on the switch.
The ground worker, realizing he was not going to convince
his colleague to put on the voltage-rated gloves then called out
the next step for the installation of the grounding cluster. The
aerial worker again stated "No need," pointing out that he was
on overtime and just wanted to get home. Installing the ground
clusters would take ten minutes and removing them would take
ten minutes and that was twenty minutes more away from
home and dinner and the aerial worker wasn't going to spend
that time satisfying the whim of a new supervisor. He had
spent over thirty years working without grounding clusters and
was not about to start now.
The ground worker then instructed the aerial worker to stop
work, pointing out the new policy implemented by the new
supervisor allowed anybody to order a stop-work at any time for
any reason . The aerial worker continued working on the
switch, stating that he was not going to lose another evening to
working on the switch on some other day.
A couple minutes into the repair, the aerial worker managed
to contact a line and a grounded point at the same time,
discharging the capacitive build-up in the line. He screamed in
pain and the ground worker asked, "What happened?" The
aerial worker responded , "It bit me!"
A discussion ensued during which both workers came to the
conclusion that since there was no work occurring immediately
proximal to any energized 13.8kV, that the shock was a DC
shock, the result of the aerial worker discharging the capacitive
buildup on one of the lines. Satisfied with that conclusion, the
aerial worker completed the repair and lowered the bucket to
the ground.
The workers followed the remaining steps in the procedure,
removing the lockoutltagout to reenergize the line and restore
power to the site.
The ground worker then offered to drive the aerial worker to
the hospital, citing the company policy they had both signed-off
on the day they were hired that any electrical shock required
immediate medical attention. The aerial worker refused the
offer saying, "No need" and stated he had already lost enough
time away from home and didn't want to lose any more to a
hospital visit, reminding the ground worker that he had taken
dozens of shocks in his career and this was all in a day's work.
The two workers then went their separate ways.
Later that evening, about six hours after the shock occurred,
the aerial worker's wife noticed he was having cognitive issues
and, despite his protests of, "No need, " insisted on driving him
to the hospital where it was determined that he was in
fibrillation. It took three attempts with the defibrillator to get his
heart back to a normal rhythm . The worker was given a less
than fifty percent chance of surviving the night, remained in the
hospital for nine days, and was off an additional six weeks
before being released back to work.
Upon his return to work it was determined that, due to the
2
length of time his brain was insufficiently oxygenated, his
cognitive abilities were no longer sufficient to permit him to
perform work at a journeyman level and he was relegated to a
helper position for the rest of his career.
The Investigation
A formal root cause analysis investigation was conducted by
the corporate incident investigation department. The supervisor
presented documentation of the worker's training in
lockoutltagout, use and application of voltage-rated gloves, and
installation and use of grounding clusters. Also provided were
copies signed by the worker of the outage procedure and the
company policy with respect to the requirement for immediate
medical attention in the event of an electrical shock.
Testimony was also presented by the ground electrician as to
his efforts to get his colleague to comply with the steps and
requirements in the procedure and his attempt to get the co-
worker to the hospital for treatment.
Two weeks later, the root cause analysis team returned with
determination that the root cause of the incident was
'Management Failure.' A stunned first-line supervisor, armed
with signed training documents, signed procedures, and signed
policies, asked, "What more could I have possibly done?" to
which the head of the investigative team replied , "What is in
your company's policies, procedures or programs to that would
lead this person believe that there would be any consequences
for this actions?"
It was difficult for management at all levels to accept the
conclusion of the root cause analysis team but after some
serious introspection the following conclusions were reached.
1 - Developing policies, programs, and procedures, and
training not enough. It is important to train as to the 'why' of the
procedures to help employees to understand this is not another
flavor of the month but a serious commitment on the part of the
company to safety. Training as to the 'why' of the requirements
also assists the worker in understanding the potential electrical
hazards in order to raise the awareness of the worker so the~
can implement the self-discipline called out in the NFPA 70E c
Standard.
2 - Management must walk the talk. Management had a
history of not addressing safety issues. There was a pattern of
policies and procedures put into place and not enforced. There
were repeated instances of minor and major safety incidents
being ignored, swept under the rug, or diminished as being 'not
really all that bad.'
Corrective Actions
Corrective actions were very slow in coming . There were
pockets of management very resistive to the concept that this
incident was evidence of a systemic management problem and
not an isolated incident, the result of a non-compliant employee.
The implementation of corrective actions was much more of a
journey than a destination.
Today, however, the company has a zero tolerance policy
toward deviations from procedure or policy. Deviations will
result, at the very least, in suspension without pay and can
result in immediate termination .
Employees are also presented not with just a set of
mandated rules, but an education to the reasoning behind the
rules, including training on the effect of shock on the human
body, enabling them to understand the 'why' behind the rules.
CONCLUSION
A serious electrical shock incident occurred because an
employee failed to understand the 'why' behind new safety
requirements. Much of that failure was due to a management
failure to adequately communicate the 'why' behind the
requirements as well as a historical failure of management to
follow through with consequences for negative employee safety
behavior.
ACKNOWLEDGEMENTS
The author gratefully acknowledges Emily Kowalchuk for her
critical reading and comments on this paper.
VITA
Wes Mozley is an Electrical Engineer responsible for the
implementation of the Arc Flash Program at Sandia National
Laboratories in Albuquerque, New Mexico, where she has
worked for over 35 years. Originallyan electrician by trade,
Wes worked primarily in industrial maintenance and
construction in both high and low voltage applications. In
addition to carrying tools for many years, she has worked as a
supervisor, inspector, designer, contract manager, quality
engineer, and maintenance engineer. Wes has taught in the
Electrical Trades department of Central New Mexico
Community College since 1984 and also runs her own
consulting firm providing electrical safety, maintenance, and
forensic consulting, safety and electrical training, and
continuing education. Wes enjoys travel, woodworking ,
handcrafts and gardening.