Near-Miss Program of the
IBEW Local 1245 Safety Committee
The primary purpose of this web page is to serve as a safety awareness tool for our members as well as others in the industry to share experiences that could have resulted in a reportable/recordable injury or property damage, but due to either the experience and/or the luck of the individual(s), no harm or damage occurred.
A near-miss or close call is a “second chance” or a “gift” and it is up to the individual who got the second chance to pass the information along so that everybody benefits from it. The next person walking down the same path may not be as fortunate. A near-miss that goes unreported is a wasted experience that could possibly have saved a life someday.
The near-miss could be the result of equipment failure, hardware failure, or unintentionally not following established safety rules.
All near-miss reports will be posted to this web page as received, with only minor editing if required for clarity or to maintain anonymity. E-mail your near-miss to Near-Miss.
It is important to note that the use of company computers for anything other than company business could result in disciplinary action so we strongly encourage the use of members’ personal computers when submitting anything to the Safety Committee.
The following archive of near-misses on the job is compiled by date, with the most recent entries listed first.
Posted: 9-6-12
A near miss was recorded from a line crew while lifting a 750 lb. 50kva transformer. The crew was in the process of pulling the transformer from the pole using a steel Wilson gin. All of the work was being done by a journeyman climber on the pole. The crew had covered the 12kV primary above while making the lift when the winch line became very taut. The operator reported 1000 lbs. of pressure on the capstan pressure gauge. After several attempts to work the transformer from the pole the transformer came loose and was ejected from the pole an estimated 18”. The transformer remained attached to the fiber sling and winch line but the violent action shook the pole top and primary. The rubber cover prevented the equipment from coming in contact with the primary. The crew found that the transformer hanger had been flattened out preventing it from easily being lifted from the pole.
Posted: 9-6-12
A crew working maintenance on a 12kV UG radial line made phase to ground contact on a transformer case. A journeyman lineman in the process of doing a voltage test was pulling a capacitive test cap on an energized dead break elbow when the elbow became dislodged from the transformer bushing and fell onto the case of the transformer. The phase to ground contact caused a large arc flash and blew a single fuse at the termination pole. The remaining fuse caused a primary backfeed which kept the dead break elbow energized and the arc flash sustained. There were no injuries to the crew and an examination of the incident revealed that there were no spring bails installed on the elbow to keep it secured to the transformer bushing.
Posted: 9-6-12
While working on a scheduled outage a crew was performing maintenance on a UG 3 transformer radial run. The crew had first planned to de-energize the whole radial circuit but changed their minds and decided to keep the first transformer in the run energized. Switching was performed and the isolated cable was grounded. After the work was completed grounds were removed and two journeymen were positioned at the first transformer while the other crew members went to the termination pole to de-energize the line. For unknown reasons and against instructions the journeymen at the transformer removed the bushing dummy cap and plugged the energized cable into transformer. This caused a fuse to blow at the fuse pole. No injuries or damage to equipment occurred but the crew foreman reported it as a near miss because if under different circumstances the linemen did not follow procedures the result could have been catastrophic. The linemen at the transformer admitted that they did not understand the instructions.
Posted: 7-2-12
Energized Transmission Grounding Incident: It was reported to committee that a crew mistakenly applied personal protective grounds to an energized 69kV transmission line. According to the report the crew had tested the line de-energized with a Hastings voltage tester and applied the grounds causing the 69kV relay. No injuries were reported and the incident has been investigated and the supervisor involved. The crew claimed that the voltage tester failed to tone” that the line was energized causing them to mistakenly conclude that the line was de-energized.
Posted: 7-2-12
Primary Splice Failure: Contract crew was energizing a new run of primary cable in a man hole. When the foreman put the switch in the closed position to take rotation at the 3 pot bank he noticed he had no voltage. He then returned to the switch and noticed it was not closed all the way. He the reclosed the switch at this time it caused a fire in the man hole at the cable. After reviewing the man hole we discovered a failed primary splice. Upon further review the cable was 25kv to 15kv where the straight splice failed. The splice used was a 25 kv straight splice. This is the incorrect splice for this cable and caused a .09’’ difference on the 15kv side of the cable causing a path to ground and the cable to slow burn itself in the clear and not a complete fault. Upon review of the other work locations adjacent to this manhole three additional splices of the same nature where located and replaced.
Posted: 6-13-12
On May 4, 2012 a 480 volt circuit was inadvertently energized briefly while a crew was on the other end of the circuit at a power plant. The crew recognized the circuit as energized when a piece of equipment began working for approximately 90 seconds. This circuit was under a clearance and the breaker that was believed to become energized was Tagged out (No Lock) as per plant procedures. There were no injuries since the crew recognized that the equipment that started up was under clearance and stopped working. An investigation into the cause of this incident has taken place and report pending.
Posted: 3-6-12
On February 11, 2012 while performing a 1 ¼ inch valve change, a Gas Service Representative encountered problems with a valve changer. During the process of changing the 1 ¼ inch service valve, the rubber plug on the shaft tube extended above the riser causing gas to blow to atmosphere after the service valve was removed. The GSR was unable to reinsert the shaft tube to seal off the blowing gas. Due to the rubber plug being installed incorrectly, the service valve was not able to be reattached. 911, dispatch and a supervisor were called and immediately informed of the blowing gas. M&C Gas arrived on site to dig up the gas service and squeeze off the gas flow.
Posted: 1-30-12
Two employees were setting up to drill a hole for a ground support in the bottom of a circuit switcher control cabinet. The lead foreman told his crewman to wait until he had his low voltage gloves on before drilling the hole. The Lead was intending to hold a bundle of energized control wires out of the way so the hole could be drilled without damaging the wires. Either the crewman ignored or did not hear the lead and proceeded to drill the hole. The crew foreman yelled to the crewman to stop just as the drill nicked the insulation of one of the wires that supplies power to the cabinet heaters.
Potential For Injury:
The crewman could have received a small electrical shock or bound the drill causing an ergonomic injury.
Events Leading Up To:
Poor communication, Poor job planning.
Immediate Corrective Action:
Both the A/C and D/C circuits to the control cabinet were de-energized and there was enough slack in the first junction box to remove the effected portion of wire and re-attach the wire inside the cabinet.
Future Prevention/Elimination:
The crew discussed the proper use of three way communication to eliminate future related incidents from happening. They discussed how the HPI tools we are taught to use and if used properly can prevent possible injury or equipment damage.
Posted: 11-1-11
While delivering a load of material using the long line method from a helicopter, the pilot noticed some debris fly away in his peripheral vision when the helicopter main rotor blade contacted a small branch on a large pine tree. The pilot did not feel the contact and it did not affect the ship’s operation. The pilot had delivered a number of loads using a 150’ longline with 40’ slings and a manual snap eye. The operational conditions were as follows: the weather was clear, little or no wind, there were large trees at the site, the ground crew had radio communication with the ship, and completed tailboard with crews. The pilot had just placed the load and was waiting for the crew to hook the empty slings back on, when the ship drifted slightly to the left, contacting the small branch. The pilot then notified the crew by radio of a blade strike” and flew the ship to a designated landing zone. He shut the ship down and contacted his helicopter maintenance manager who instructed him to perform an inspection procedure on the helicopter main rotor blades. The pilot completed the inspection procedure, reported the results to the maintenance manager who cleared the pilot to resume flying. The pilot flew back to the jobsite where the pilot and the ground crew tailboarded the incident and on the work to be completed. The pilot completed thirteen more picks, with no further problems.
A structure erection crew was in the final stages of setting a Tubular Guyedí¢”š¬V (TGV) structure when one of the 7/8″ guy wires gave way, allowing the tower to twist in a counter clockwise direction. As the tower spun, the twisting motion allowed the guy wire to get tied up into the shackle release rope. Ultimately pulling the release shackle on the west side of the spreader bar, where the tension on the load line of the crane had just been “slacked off “to accommodate the plumbing of the structure. After the release shackle was pulled out, it let go of the sling that held the spreader bar on the west side of the arm. This allowed the tower to continue rotation counterclockwise until the entire load was suspended by the east side of the spreader bar. Once the weight shifted to that location, the crane rotated counterclockwise, sliding three of the outriggers off their pads. At that point, the operator remained calm and had the presence of mind to hold the swing brake on in order to keep the load from continuing to swing, thereby avoiding the potential of the structure to cause harm or damage. Before the incident occurred, the setting crew methodically stood up the tower without incident, and attached the four guy wires down to their respective anchors. The tower was plumbed with the use of “airline blocks” (4 part blocks) which are attached to the down guys and anchor attachments, with the fall line of the blocks being attached to the winches on the front of the crew trucks. In the process of plumbing the tower, the appropriate steel grip attaching the winch cable to the airline block “fall line” was sucked into the block causing the grip to be knocked off, once this happened the airline cable ran approximately 50′ of cable through the blocks until the eye hit the block. As the eye hit the block it created a shock G .. ., u p wave which transferred up to the grip on the 7/8″ down guy kicking it off the guy wire. Within a very short period of time the tower began the counterclockwise rotation previously described. After the load had safely settled, and the side load removed from the crane, the crew safely lowered the tower back to the ground, without injury or equipment damage. The crane has been inspected by the Crane Manufacturer as being safe to operate and no harm was done to the boom of the crane. Root Causeí¢”š¬ the near miss is due to the lack of attention to detail. With the grip nearing the blocks, the crew should have cut off the guy wire and lengthened out the blocks to avoid having the grip come into contact with the blocks.
Posted: 5-17-11
During an outage to replace a water leak in a power plant the water supply to a chemical lab needed to be shut off. To mitigate the issue of clearing the eye wash and drench showers to the lab that is required to be operational the company decided to bring in a temporary drench shower and plumb it into an operational water supply while work was performed. During a walkthrough of the facility by another employee it was discovered that the temporary shower was hooked up to a hot water supply line with the potential to deliver hot water (158%) to the drench shower if needed. Work was stopped until the supply line was transferred to a cold water supply line. The supply line used was also too small to deliver the required amount of water to the drench shower (20 gpm). No accidents or need to use the shower occurred during this outage however the potential of further injury and or inadequate measures to adequately deal with an exposure to employee were present.
Posted: 1-4-11
CableCom LLc was installing fiber optics in Angwin. What is significant is that one of their guys rode a PG&E secondary pole down till it hung up in some trees The pole was rotted off completely at base, tagged N (PG&E designation for rotten, not stubbable, replace). They were installing and wrapping fiber optics through trees. Pole held only communications and dead-end open wire 1/0 alum secondary with one service. Tag indicates it is scheduled for replacement, but likely low priority as inaccessible, only secondary, and in Angwin. I talked with CableCom foreman and his main concern was retrieving the binding tool left on the line, and somewhat relieved that no injury. I explained the meaning of the PG&E tags, as there are plenty on the hill that are rotten and it could happen again. Pole could have been climbed if supported, and I would hope that any lineman at PG&E would have seen the tag…of course, any lineman from anywhere should have had the self-preservatory instinct to support this pole.
A crew had energized wire come down while replacing a deadend bell. A journeyman and hot apprentice were in bucket preparing to change a deadend, when they thought the wire pulled through the tie on the adjacent pole. When they came up on the hoist a couple clicks the wire separated from a strain sleeve (nico pressed sleeve) at the other pole. The wire fell in between the secondary and phone hitting the ground at the base of the pole, it arced off of a stop sign briefly before the guys in the air cut it in the clear. It was discovered that a 1/0 sleeve was pressed on the 2 strand primary which caused the failure. No one was hurt during the incident.
Report of a tire blowout on a new trouble truck that had less than 7,000 miles on it. The tire brand was Continental. If anyone else has experienced a similar occurrence with this brand of tire let us know
While getting ready to pull old poles, crew had boom out and heard a thud on the ground. Evidently a large shackle which had been affixed to the upper part of the underside of the boom had fallen off its holding eye. After some brief investigation, it was revealed that the straight pin use in the shackle had a missing cotter pin. Luckily no personnel were injured.
On 4/27/10 I had a call to a car-pole accident. I arrived to find an aluminum street light pole with what I thought to be 120/240 volt street light heads. I was asked by the Fire Department to clear the wires so they could move the pole out of the street as this was a City of San Mateo pole. I found the energized wires clear of the pole and only had to cut the ground wire and tape the other ‘energized wires.’ I did not find any ‘high voltage’ signs on the splice box nearby or on the pole. I was surprised to find that this was a high voltage system when the city worker asked me to de-energize the R.O. (regulated output) circuit which can be 2400+ volts to ground. This is primary voltage, but it was not marked as such in this case. The box was just marked ‘Street Lights’, and not ‘High Voltage’. These voltage wires go right up into the street lights. This could be dangerous because it is not properly marked, and any worker could be mistaken into thinking he’s working with 120/240 volts when in fact he’s working with high voltage. If they’re not wearing proper PPE this could have negative consequences. Additionally, the splice boxes are not bolted down as they should be for high voltage conductors.
These lights are 100% owned and maintained by the City of San Mateo.
We keep saying that reporting near-misses can help us avoid similar hazards in the future. And now we have some evidence that near-miss reporting works!
A four man line crew was removing jumpers on the upper circuit on a 3-wire double dead-end pole. The pole also had a buck line feeding one way to a set of cutouts which were closed. The downstream side of the feed had all transformer fuses open to remove any load potential. The upper circuit was #6 solid copper and the lower buck wire was # 4 ACSR. Two journeymen were in a double bucket using 8-foot shotguns to open and transfer the wire into the clear.”
As the aluminum drop-on was being removed from the upper circuit the wire broke pulling the jumper wire into the lower circuit causing a ball of fire and blowing two upstream 80 amp fuses at the feed pole. Both linemen were uninjured and there was no other damage to company or customer property.
It was determined at a crew tailboard meeting shortly after the incident that there was one main cause for the accident. The drop-on clamp being removed was made of aluminum and although the #6 copper was line guarded a high resistance connection had developed causing the wire to degrade at the tap location. The lineman reported that the drop-on clamp was practically frozen onto the copper wire, but after some pressure it started to turn and then the wire broke. He also reported that there was no indication of any corrosion as the drop-on was covering the bad spot.” Our company policy long ago has prohibited the use of copper/aluminum combination drop-on connections, but in this case the construction was about 50 years old.
Approximately two weeks after this incident was reported in a department-wide near-miss discussion, a crew working storm damage encountered a similar incident in which a frozen” drop was caused by another corroded connection. In this case the crew cut out the tap with hot cutters and made repairs. The foreman of the crew said that he was glad the first near miss was reported. It increased awareness and helped avert another potential accident. Here it is: evidence that near-miss reports works!
Two linemen were in a double bucket truck while a troubleman was clearing the line. When the dispatcher opened an inertia switch, the switch exploded, energizing phone line where the two lineman were located. There were no injuries and the crew pulled off the job until they were 100% certain that the job could be done safely. There have been several failures of these switches recently, which led this committee to question administrative controls by the company until the problem is corrected. The manufacturer of the switch has identified the problem and has started a retrofitting existing switches that are suppose to eliminate the failures. It is advised to stay clear of these switches and anything that could be energized in the event of a failure until all switching is complete.
Two linemen were in a double bucket truck while a troubleman was clearing the line. When the dispatcher opened an inertia switch, the switch exploded, energizing phone line where the two lineman were located. There were no injuries and the crew pulled off the job until they were 100% certain that the job could be done safely. There have been several failures of these switches recently, which led this committee to question administrative controls by the company until the problem is corrected. The manufacturer of the switch has identified the problem and has started a retrofitting existing switches that are suppose to eliminate the failures. It is advised to stay clear of these switches and anything that could be energized in the event of a failure until all switching is complete.
Third party ran over a pad mount transformer. After the transformer was de-energized but before grounds were applied the supervisor on site ordered the tow truck driver to pull the vehicle off of the transformer. A warning to all should be given that if it is not grounded it’s not dead.
While working on and around a 1600A electrical panel, electricians had noticed that the main switch handle was broken. Since the spring in a 1600A panel is fairly strong, a pair of channel locks was being used to operate the switch. In the course doing their routine work, one of the electricians discovered that the metal that was exposed, underneath the broken insulated handle, was in fact directly connected to B phase of the panel. They tested it at full voltage.
So, the heads up here is that many of us in the electrical trade did not consider the parts of the handle in a main switch as being directly connected to live electrical buss. This case proves that assumption to be false. In this case, someone working on this panel, or a maintenance person coming in contact with this expose metal could have been injured.
Although it is not known what the age of this breaker is, it would be best to consider all parts of any breaker as energized until testing.
This is another reason to replace a breaker when there is any damage to the handle.
While performing the work in the course of connecting a large commercial customer, a utility service crew was testing and inspecting the newly connected conductors from the customer’s main panel to the service connection point.
The panel was a 3000A panel, with multiple compartments for the landing section, meter section, Main, and distribution circuit breakers.
By coincidence, the meter technician from the utility was there at the same time, doing his meter wiring for the current coils.
The service crew completed all of their tests, and everything proved to be phased and connected in a correct manner.
At the end of this process, just as the service crew was re-installing the panel covers, the meter technician noticed something in the rear of the panel that did not look right.
The service crew went to get a flashlight. Upon further investigation, it was discovered that a bag of connecting bolts for the panel had shifted during shipping. It had landed between the main buss bar of A phase and the back of the main board panel. It was a plastic bag, full of bolts, nuts, and washers. Although the plastic had worn through on many different places on the bag, none of the metal items in the bag had connected a path to the grounded panel cover in the back of the panel. Therefore, the continuity test had proved normal.
As the crew was attempting to free up the bag and remove it, the electricians arrived. They said, “So, that’s where that bag of bolts went. We assumed the factory never sent them, so we had to order another bag.”
This incident reveals why it is necessary to make a good visual inspection of any and all equipment. None of us can ever predict what kind of hazards that might be present, so expect the unexpected.
In this case, the plastic on this bag of bolts could have deteriorated over time with the increased temperature of the panel under load. Upon making contact with the grounded panel surface, it could have acted like a bomb, perhaps sending small metal fragments out in all directions. It is likely this would have been catastrophic, with devastating consequences for the customer power equipment. More important, a catastrophic event of this nature could cause injury or death to anyone in the vicinity.
Personnel at a Power Plant avoided a significant near miss. At approximately midnight on a Sunday morning a main bank “C” phase transformer, which is in the area just east of the turbine building at an elevation of 85′ exploded. The blast sent debris into the North side of the Administration Building through several windows as high up as the fifth floor. Although there is no mention of the safety hazard of this event from plant-wide communication, one employee wrote an AR (Action Request) re: the personnel safety issue and the need to evaluate the impact on personnel safety for those individuals on the North Eastern portion of the Admin Bldg. Significant injury was avoided solely due to the time of incident.
A 4-man crew was performing some switching to open up a loop system in correlation with the control center/and switching orders. The crew arrived at the job site and the switching orders called to open a parallel system at a set of down jumpers. The two journeyman linemen proceeded to remove the first jumper… with the hotline clamp in a grab-all stick the lineman proceeded to lift the hotline clamp. As the clamp was lifted a large arc grew from the wire to the newly lifted clamp, causing concern to the lineman who placed the jumper back in the original position and informed his foreman that something didn’t seem right, and to call the control center to verify regulations between the two stations were set. The control center confirmed that everything was in order to proceed with lifting at the jumpers. The lineman got back into position and lifted the clamp again only to experience a larger arc now jumping a gap of approximately 3-4 feet from the wire to the lifted clamp! The lineman again placed the jumper after not being able to break the arc with the 3-4 foot swing ability of the jumper. The crew decided to look for a safer way to open the load by mounting a set of cut-outs at a different location and opening it with a load break device. Once this was done a couple of customers asked what happened to their power and why it was disrupted? Further review of the situation revealed that the control center failed to notice an open point in the line causing the crew to drop load between the open cut-outs to an already existing open point. The jumpers lifted were breaking load and not indifference between the stations. (Posted August 20, 2008)
A troubleman while performing routine switching for load reasons was operating various overhead switches with permission of the control center. Arriving at a newly installed switch the troubleman proceeded to close the switch which unfortunately caused a large outage. Further investigation revealed that the newly installed switch was not properly terminated resulting in a phase to phase fault de-energizing two stations and many customers. The switch was not damaged and no injuries were reported. (Posted August 20, 2008)
While stringing in a new conductor for a 4 wire 12kV overhead line an apprentice lineman, in the process of catching off the first phase with a grip and a sling had removed a ground cable to better position the newly landed wire to allow for the next run to be pulled in. The apprentice was controlling the tail of the new phase so it wouldn’t flip around and possibly get into any energized equipment on the other side of the pole. Once he removed the ground lead he became in series with the line causing him to receive a shock. No injuries were reported from this incident. (Committees discussion regarding this incident is that we will post this as a near miss but this is considered an accident and should be reported as such. We are not sure of the severity of the shock but want to emphasize that medical evaluation and accident reporting with the employer should be done when the severity of a shock is enough that it could upset normal heart rhythm which could happen with secondary voltages.) (Posted August 20, 2008)