Appendix C - Causal Factor Analysis Examples cont'd

Findings included:

The regular electrician was sick so a substitute who was not trained on high voltage was

used (Cause Code 5A, No Training Provided).

The substitute did not follow procedures. The substitute tied out the interlocks and used

the wrong meter (Cause Code 3C, Violation of Requirement or Procedure).

The fuse obtained from the storeroom was outdated and was no good (Cause Code 1A,

Defective or Failed Part).

The large fan was not designed for cycling (frequent startups) and had been regularly

blowing fuses (Cause Code 4B, Inadequate or Defective Design).

The supervisor knew the substitute was inexperienced but did not observe the substitute

or give any special assistance (Cause Code 6C, Inadequate Supervision).

Known defects had not been corrected (Cause Code 6A, Inadequate Administrative

Control).

To correct these conditions, the following recommendations were made:

Investigate and repair the system so that it does not blow fuses.

Train supervisors to ensure that the worker is qualified for that task.

Provide high-voltage training as needed.

Evaluate management response to safety problems and operation of malfunctioning

equipment.

As a result of the potential significance of this occurrence, a formal, detailed root cause analysis was

performed. A high level of effort was expended but the effort was justified due to the consequences of a

repeat occurrence.

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