January 2005

Electrical Safety DuringExcavations and Penetrations

Independent OversightLessons Learned Report

Office of Independent Oversight and Performance AssuranceOffice of Security and Safety Performance AssuranceU. S. Department of Energy

SSA

Office of Security and SafetyPerformance Assurance

OV

ERSI

GH

TTable of Contents

1.0 INTRODUCTION ........................................................................... 1

2.0 RESULTS ......................................................................................... 3

3.0 CONCLUSIONS .............................................................................. 7

4.0 OPPORTUNITIES FOR IMPROVEMENT ................................... 9

Abbreviations Used in This Report

CFR Code of Federal RegulationsDOE U.S. Department of EnergyEM Office of Environmental ManagementGPS Global Positioning SystemKCP Kansas City PlantLLNL Lawrence Livermore National LaboratoryNNSA National Nuclear Security AdministrationOA Office of Independent Oversight and Performance AssuranceORNL Oak Ridge National LaboratoryORPS Occurrence Reporting and Processing SystemOSHA Occupational Safety and health AdministrationPPE Personal Protective EquipmentSC Office of ScienceSRS Savannah River Site

FOREWORD

Since 1984, the Office of Independent Oversight and Performance Assurance (OA), within the Office of Securityand Safety Performance Assurance, and its predecessor offices within the U.S. Department of Energy (DOE) havebeen responsible for evaluating programs of national significance and reporting on their status to the Secretary ofEnergy, senior Department management, and Congress. This independent internal oversight function is unique in theexecutive branch of the government and, over the years, has led to notable improvements in safeguards and security;cyber security; environment, safety, and health (ES&H); and emergency management programs. The OA Office ofEnvironment, Safety and Health Evaluations is responsible for evaluating and reporting on ES&H performancethroughout the DOE complex.

A number of DOE sites have electrical wiring or utility lines that are not well marked or accurately reflected on sitemaps and drawings. Previous inspection results and event reports indicate a number of events and near missesduring excavation of buried utilities and during penetration of building structures. Therefore, OA identified electricalsafety during excavations and penetrations as a focus area—one that warrants increased attention across DOE—during four fiscal year 2004 inspections: Lawrence Livermore National Laboratory, Oak Ridge National Laboratory,the Kansas City Plant, and the Savannah River Site.

As discussed in this lessons learned report, sites have taken significant steps in recent months to increase electricalsafety during excavations and penetrations as a result of increased management attention. However, furtherimprovements are needed in the areas of configuration control, utility location surveys, procedure quality, and adherenceto established requirements.

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Introduction1.0

Table 1. Sites Inspected by OA During 2004

Safety ManagementInspection Site

Savannah River Site (SRS)Kansas City Plant (KCP)Oak Ridge National Laboratory (ORNL)Lawrence Livermore National Laboratory (LLNL)

HeadquartersProgramOffice(s)

EM/NNSANNSASCNNSA

This report summarizes the observations,insights, and lessons learned from evaluating theelectrical safety during excavations andpenetrations during Office of IndependentOversight and Performance Assurance (OA)environment, safety, and health (ES&H)management inspections conducted in 2004. OA,within the Office of Security and SafetyPerformance Assurance, identified electrical safetyduring excavations and blind penetrations as a focusarea across the U.S. Department of Energy (DOE)complex based on an analysis of past inspectionsand other performance data, which determined thatthere have been a number of events and nearmisses at many DOE sites. In 2004, this focusarea was evaluated as part of ES&H inspectionsat the four sites listed in Table 1. The table alsoidentifies the DOE program office that has primarymanagement responsibility for each site: theNational Nuclear Security Administration (NNSA),the Office of Environmental Management (EM),or the Office of Science (SC).

The focus area of electrical safety duringexcavations and penetrations was selected for 2004based on a review of previous inspections andoperating experience (e.g., occurrence reports)which indicated performance problems in this area.Workers involved in these occurrences wereemployees of DOE prime contractors and theirsubcontractors. A DOE Headquarters OperatingExperience and Lessons Learned Report in

April 2004 noted that excavations that struck buriedelectrical utilities occurred and were reported oncea month, on average, during 2002 and 2003,primarily during construction. Many of theoccurrence reports listed inadequate as-builtdrawings or lack of drawings as a major causalfactor. Other causal factors included failure touse locating equipment, and not complying withexcavation procedures, (e.g., not hand-digging nearburied electrical lines). In some occurrences,survey equipment was used but did not accuratelylocate buried utilities. Energized electrical lineshave also been struck during penetration of floors,walls, and ceilings (i.e., “blind” penetrations).These events have also occurred about once amonth during the past three years. Most suchevents involving blind penetrations occurred whileworkers used hand tools to drill or cut into facilitystructures during construction and demolition.Electrical systems that remain energized to supportdemolition activities (such as lighting circuits) havealso presented a particular challenge for this typeof work; in a number of cases, the energizedsystems were not properly marked, locked out, ortested to verify zero energy.

Section 2 of this report discusses OA’sobservations, including positive attributes andweaknesses. Conclusions are provided inSection 3, and opportunities for improvementderived across the four sites are presented inSection 4.

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Results2.0

DOE and NNSA Headquarters and fieldorganizations have taken significant steps toimprove electrical safety across the complex.However, a number of challenges need to beaddressed to further enhance electrical safetyduring excavations and penetrations. Because site-specific deficiencies and opportunities forimprovement have already been communicated tothe sites as part of OA’s inspection reports, theimprovement items in this report focus on potentialenhancements of DOE performance across thecomplex. However, where appropriate, OA refersto positive attributes at specific sites so thatinterested parties can obtain additional informationabout innovative approaches and noteworthypractices (e.g., by referring to the applicableES&H inspection report or by contacting the site).

Positive Attributes

DOE and NNSA Headquarters haveprovided direction that has led to improvedelectrical safety during excavations andpenetrations. In April 2004, the Deputy Secretaryof Energy declared May 2004 as Electrical SafetyMonth and chartered an Electrical Safety AdvisoryGroup to address electrical safety risks across theDOE complex. Supporting these initiatives, a draftrevision of the DOE Electrical Safety Handbookincludes safety guidance for excavations andpenetrations in the vicinity of buried and embeddedelectric utilities. In addition, an electrical safetyperformance improvement program wasestablished that includes tracking and trendingperformance in electrical safety, developing plansto strive for improvement, providing a quarterlystatus report to the Deputy Secretary, andidentifying sites that have excellent performancerecords and “Best Practices.” DOE and NNSAcontractors have responded by developing andimplementing initiatives to improve electricalsafety. Although the Headquarters directives donot specifically address electrical safety duringexcavations and penetrations, most siteimprovement plans include steps to improve safetyin these areas—for example, purchasing better

instrumentation for locating buried utilities,developing better procedures and permit processes,and providing training for individuals assigned tolocate utilities.

Each site inspected by OA has establishedprocesses for ensuring that electrical hazardsare identified before excavations orpenetrations begin. Hazard identificationincludes establishing the location of electric utilitiesthat are buried underground or imbedded in thefloors, walls, and ceilings of structures. Thelocation of buried utilities is determined based onreview of drawings and the results of surveys madewith specialized location instrumentation. Onceidentified, the locations are marked on the groundwith paint, flags, or other markers. Controls, suchas lockout/tagout, personal protective equipment(PPE), and hand digging, are then established toreduce the risk of electric shock during digging.Similar processes are used to reduce the risk ofshock during penetration of masonry floors, walls,and ceilings. Penetrations in hollow drywall aretypically made by cutting small holes in the drywallto allow visual identification of electric utilities insidethe walls before more extensive drilling or sawingbegins. Controls for blind penetrations typicallyinclude lockout/tagout and PPE.

The DOE/NNSA management focus onelectrical safety management, combined withcontinuing events involving electric shockand near-misses during excavations andpenetrations, has resulted in heightenedawareness of electrical safety risks associatedwith this work. This awareness has prompted anumber of programmatic improvements at all ofthe sites visited by OA in 2004. New programshave been established for locating buried utilities,instrumentation has been upgraded, training hasbeen improved, and administrative processes havebeen strengthened. Examples of programimprovements and effective practices at one ormore sites include:

• Each site inspected by OA has established aformal process for identifying electrical hazardsbefore performing excavations or penetrations.

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These processes require that utility locationactivities be completed and documented onexcavation/penetration permit forms, and that thesepermits be approved by authorizing individualsbefore work begins.

• Each site visited by OA requires the use of non-destructive digging techniques within a specifieddistance of buried utilities. For example, at somesites, workers use vacuum excavation equipmentto remove soil that had been loosened with air orwater jets. At LLNL, vacuum excavationequipment is used routinely to dig “pot holes” asan exploratory technique when the exact locationof utilities is not known.

• LLNL is placing electronic marker balls withutilities before backfilling excavations. Eachmarker ball has an electronic system that can beexcited by an above-ground instrument. Whenexcited, the ball transmits a digital code that is usedto positively identify the marked utility, its position,and its depth. Straight utility runs are marked at100-foot intervals, and all turns and junctions aremarked.

• LLNL has also established a comprehensivetraining and qualification program for individualswho use utility locator instrumentation. Traineesparticipate in six months of on-the-job training,which includes working with qualified site locatorpersonnel. After six months, they are sent to anindustry locator training course, which includes 40hours of classroom training on the theory andoperation of utility locator instruments, and a seriesof practical exercises. At the end of the course,each locator must successfully complete a finalpractical exercise in order to be certified as a utilitylocator. Individuals are not authorized to workindependently until they have completed this course.

• ORNL plans to use global positioning system (GPS)equipment to identify the location of undergroundutilities with greater precision.

Weaknesses

Observations by OA during recent safetyinspections, along with continuing events involvinginadvertent contact with buried and embedded electricutilities during excavations and penetrations, indicatethe need for additional improvements. Specific areaswhere improvements are needed include configurationcontrol, utility location surveys, procedures and

processes, and adherence to established requirements.These areas are discussed in the following paragraphs.

Configuration control programs at most sitesdo not include current and accurate drawings. Theuse of outdated and inaccurate drawings is a commonfactor in many excavation/penetration events reportedin the DOE Occurrence Reporting and ProcessingSystem (ORPS). Site personnel acknowledged thatdrawings were out-of-date at each site visited by OA.While each site has drawings that show buried andembedded electrical utilities, these drawings have notbeen consistently kept up to date with as-built conditionsand modifications, and thus the drawings cannot beregarded as fully reliable. Most sites lack an effectiveprocess for updating drawings when utilities areidentified in locations other than those shown ondrawings, and none have plans for reconstitution ofsitewide drawings.

The effectiveness of utility location surveysis reduced because of weaknesses in personneltraining and selection and use of equipment. Lackof reliable drawings has caused field organizations torely heavily on instrument surveys to identify thelocation of buried and embedded utilities. Thus, properuse of survey instrumentation is important for ensuringelectrical safety during excavations and penetrations.OA’s observations of surveys and discussions with theindividuals performing the surveys indicate that surveyinstruments are not always used in accordance withinstrument capabilities or vendor recommendations.Examples of such inconsistencies include:

• Surveying an area where nine-inch-deep holeswere to be drilled using an instrument capable ofdetection to a depth of only four inches

• Not using the metal detection mode when surveyingfor unidentified utilities

Excavation Event That Resulted in Cutting a Buried Electrical Line

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• Not using a semicircular scanning pattern asrecommended by the instrument vendor

• Exceeding the recommended distance between theinstrument transmitter and receiver.Only one of the sites OA visited has established a

training and qualification program for utility locators.Most sites provide little formal training to theseindividuals, and most have not established writtenprocedures for use of survey equipment. In addition,some sites have not benchmarked their surveyinstrumentation to confirm that it performs as expectedunder site-specific conditions. Benchmarking isimportant because local soil conditions can significantlyimpact instrument capability.

Procedures and processes are not sufficientlyrigorous. The OA review identified inconsistenciesin the quality of excavation/penetration permits.Workers performing excavations and penetrations relyon these permits as a source of information aboutrequired controls. The permit processes also serve asmechanisms for specifying or referencing safetycontrols. Incomplete and unclear entries were identifiedthat could result in the failure to establish appropriatecontrols. For example, penetration controls that were

specified in upper-tier documents, such as requirementsfor use of drill stops to restrict penetration depth andrequirements to review drawings prior to makingpenetrations, were not specified or referenced in somepermits.

In addition, responsibilities for locating utilities andusing penetration permits are not always clearlyspecified. For example, the split of responsibilities

between construction subcontractors and siteorganizations for locating utilities and using site permitsis not always clearly addressed in contracts orprocedures. The process at one site does not includeadequate provisions for documenting the completionof location surveys, which could lead excavators tomistakenly interpret the absence of markings to meanthat a survey had identified no utility when, in fact, nosurvey was done. Some permitting processes arecomplex, and instructions for completing permit formsare not clearly defined. This complexity is particularlyevident when both excavations and penetrations arecovered by the same procedure and form.

In some cases, procedures exempt someexcavations and penetrations from the permittingprocess but do not provide an adequate justification ortechnical basis. For example, at one site, excavationsup to 12 inches in depth were excluded, even thoughburial depth was not consistently addressed inconstruction specifications and electrical utilities hadbeen found at less than 12 inches depth. Similarly,fastener penetrations less than two inches in depth wereexcluded, even though several recent events involvedelectrical utilities embedded at less than two inches.

A number of non-electrical occupational safetydeficiencies associated with excavations were identifiedduring this review. These deficiencies included entryinto excavations by unauthorized individuals, inadequatefall protection at the edge of an excavation, excavatedmaterials placed too close to the edge of an excavation,an exclusion rope too close to an excavation, andworkers’ failure to wear high-visibility vests whilesurveying in traffic.

Management has not ensured strictadherence to requirements. Non-compliance withestablished procedures is frequently cited as a causeof reported excavation events. Although OA observedonly a few examples of failure to follow permittingprocedures during the reviews performed in 2004,procedure violations had previously caused electricutility strikes at each site visited. Site-specificexcavation procedures are written by prime contractors,and many excavation work activities are performedby subcontractors. Therefore, effective flowdown ofthese procedural requirements to subcontractors isimportant for ensuring safety; however, expectationsfor subcontractor compliance with site-specificexcavation procedures are not fully addressed in somesubcontracts. Training is another mechanism forconveying electrical safety expectations forexcavations, but some sites provide little training in thisarea.

Buried Electrical Line Cut

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2.03.0

Sites have taken significant steps in recentmonths to improve electrical safety duringexcavations and penetrations. Continuingimproved performance should result from the focusof senior management attention on electricalsafety; corporate support from the Office ofEnvironment, Safety and Health; and improvementinitiatives by site organizations. However, anumber of challenges remain that warrantincreased attention. Out-of-date drawings are asignificant challenge to reliable identification ofutility locations. The ideal solution would be todevelop as-built drawings for all sites, but the costof this effort is unlikely to be justifiable, givenbudget limitations and competing priorities. Eventhough drawings of buried and embedded utilities

will probably never be fully accurate, they willremain an important element in the identificationof utility locations, and steps should be taken tomake them as accurate as possible. Electricalsurveys for buried and embedded electric utilitieswill also remain important to safety. While siteshave made progress in obtaining and using state-of-the art survey instrumentation, improvedprocedures and training are needed to ensure theeffectiveness of electrical surveys. Excavationand penetration procedures and permittingprocesses have been strengthened in recentmonths, but additional improvements are neededto ensure that responsibilities are clearly assignedand that applicable requirements flow down tothe individuals who perform the work.

Conclusions

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4.0 Opportunities for Improvement

Opportunities for improvement in the areas ofDOE/NNSA direction and oversight, configurationcontrol, utility location surveys, procedures andprocesses, and adherence to requirements are listedbelow.

DOE/NNSA

1. At the Headquarters Office ofEnvironment, Safety and Health, as partof the overall effort to improve electricalsafety, monitor occurrence report data onunplanned electrical intrusions andprovide a periodic status report on overalltrends and outliers to senior DOEmanagement, program offices, and siteoffices for further action as appropriate.

2. At DOE/NNSA program offices, becauseof the number of incidents and thepotential for serious injury, direct siteoffices to conduct assessments ofelectrical safety during excavations andblind penetrations, including review of thelessons learned and opportunities forimprovement in this report.

3. At the site office level, sustain andstrengthen line management oversightattention on electrical safety forexcavations and penetrations, includingincreased observations of work activitiesfor assessment of procedural compliance.

Site Contractors

1. Improve configuration control by betterdocumenting the locations of undergroundutilities. Specific actions to consider include:

• Establish processes to revise site drawingsor maintain databases that describe thelocation of newly installed or reconfiguredburied or embedded utilities.

• Establish processes to revise site drawingsto reflect as-found conditions whenelectric utilities are discovered in locationsother than those shown on the drawings.

2. Enhance utility location surveys in theareas of instrumentation and personneltraining. Specific actions to consider include:

• Mark areas where excavations andpenetrations are planned using paint ormarkers to facilitate more thoroughsearches by utility location personnel.Mark underground utilities in the vicinityof the excavation in accordance withAmerican Public Works Associationguidelines.

• Test survey instruments under all siteconditions to ensure that they will performas expected.

• Establish training and qualificationprograms for individuals who performelectric utility location surveys.Incorporate the use of mockups toimprove proficiency of using equipmentfor various conditions.

• Consider the use of GPS and marker ballsto facilitate identification of utilities.

3. Enhance procedures and processes toensure requirements are clearly identifiedand communicated. Specific actions toconsider include:

• Develop written procedures for identifyingthe location of buried and embeddedelectric utilities. Consider includingguidance in the following areas: equipmentto be utilized; recommended settings andlimitations; scanning methodology (speed,direction, etc.); equipment checks; and

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safety warnings and controls (e.g., appropriatecontrols for scanning in roadways). Validatethese procedures to ensure their effectivenessin identifying electrical utilities under site-specific conditions.

• Consider developing and using an excavationchecklist to ensure that excavations are initiallyperformed correctly and are maintained in asafe condition while work is being performed.

• Ensure that Occupational Safety and HealthAdministration (OSHA) requirements andpenetration controls specified in upper-tier sitedocuments are specified or referenced onexcavation and penetration permits.

• Ensure that adequate technical bases exist forprogram exclusions or exemptions.

4. Ensure that individuals strictly adhere torequirements. Specific actions to considerinclude:

• Train individuals who perform excavations andpenetrations, including subcontractors, on site-specific procedures.

• Ensure that expectations for subcontractorcompliance with site-specific excavation andpenetration procedures are included insubcontracts. Clearly convey responsibilitiesand expectations to subcontractors forcompliance with these procedures, and holdthem accountable for non-compliance.

• Consider using checklists to verify compliancewith safety requirements associated withexcavations.

• Audit program compliance with OSHArequirements (29 CFR 1910.335, 1926.416, and1926.651), site procedures, and vendorrecommendations. Include observations ofutility location surveys.