scope:

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.)