Learning from a Near Miss Incident

Bruce Meaker, PEPrincipal Engineer

PUD No.1 of Snohomish CountyEverett, WA

NW Hydro Operators ForumBellevue, WAMay 8, 2013

Near Miss IncidentsThe disaster avoided:

usually ignored or buriedrarely talked about

Near Miss Incidents

Opportunity to learn from experiencezero-cost learning tools for safety

Established error reduction techniqueAviation Industry – 65% drop in fatal accidentsFire Rescue ServicesHealth careRail - UK

Storytelling

Jackson Hydroelectric Project1,150 ft of head (500 psi)111.8 MW2 Pelton (48.5 MW)2 Francis (8.4 MW)

Shutdown of 2003Valve seat replacement on Francis UnitsComplete dewatering of penstock

Access door

Wednesday July 2, 2003Preparing for shutdown on MondayMechanical Supervisor and 2 summer hiresSummer hire - “Do the lights go inside the

TSV on Unit 2?”Supervisor - “Yes”

What does “Yes” mean?Mechanical Supervisor: Yes, we will put the lights in through the TSV

on Monday when we have the unit shut down.

Summer hire: Yes, go ahead and do it now.

Summer hire: “Something we were taking apart for the supervisor started leaking!”

Potential losses – $15-20 MLives

2 students3 contractors 5 Powerhouse employees

Damage to power house equipment Lost power revenue Environmental damage (oil cleanup)

Lessons LearnedClearly mark access-

doors

DANGER

CONFINED SPACEENTER BY PERMIT ONLY

Lessons LearnedAll staff (including summer hires) are

to attend daily “tailgate” and pre-construction meetings.

All summer hires will sign a safety agreement when hired.

Staff will review what is and is not appropriate use of summer hires annually.

Staff will clearly communicate expectations and assignments.

Lessons LearnedWithout training and experience, we

are blind to some aspects of this technology.

The Baby Boomers are retiring in droves.

More Gen X and Gen Y age staff will be coming on site to take their place.

Getting them the training and experience to function safely is paramount.

What near-miss stories do you have?Do you share them?