**April-June 1999 *Fathom***

**Table of Contents**

**Cover**

Navy photo by PH2 Felix Garza. An ET1 checks radar equipment high above USS *Carney* (DDG 64).

**Editor’s Note**

My special thanks go to EMC(SW) Carl Henry, whose patience, understanding and technical expertise made this issue possible. Bravo Zulu on a job extremely well done. Best wishes on your return to the fleet as an LDO. I also must thank PH2 Matthew J. Thomas, USNR-R, who provided the lion’s share of photos for this issue. It was inspiring to work with someone who meets every challenge with a friendly, can-do spirit.

**Features**

**Recipe for a Shock**

The author outlines the basic ingredients for an electrical shock. By GSCM(SW) Richard Eckenroth.

# Deadly Shipmate Strikes Again                              

Three hours after an ET2 starts doing PMS on a signal-data converter in radio, an RM1 finds him dead on the deck. By ETCS(SW) Dave Williamson.

**Twist of Fate**

An MM2 dies when he grabs a metal-cased electrical-plug adapter and twists it to verify a good connection. By CWO3 Tom Fayet.

**Articles**

# Same Snake Bites Four                                    

# After four shipmates get shocked, work-center supervisors finally decide to find and fix the problem. By EMCS(SW) Michael Coleman, USN(Ret.).

**“Is This Cable Live?”**

An EM3 feels the wrath of a 440-volt cable that workers left behind when they replaced a ship’s scullery machine. By Ken Testorff.

**Top 10 Reasons Why Sailors Get Zapped**

The author looks at the 10 most common electrical problems found during surveys. By EMC(SW) Carl Henry.

**Electricity Is Everywhere...**

Electrician’s mates and electronics technicians aren’t the only shipboard Sailors who face the perils of electricity. By ET2 Fred G. Bell.

**Don’t Overload Your Outlets**

Electrician’s mates aboard USS *Dwight D. Eisenhower* are getting about 30 trouble calls a day, instead of the usual five or six, because crewmen are overloading receptacles. By JOSN Sarah Deal.

**Shock Injuries Not Always Just Skin-Deep**

Most victims of electrical shock suffer internal injuries. By Capt. James Fraser.

**Zap Puts More Zip in Your Snap**

Some shipboard Marines learn their lessons about electrical safety the hard way; others benefit from familiarization materials they receive before reporting aboard. By Ken Testorff.

**Who Takes Precautions Seriously?**

After working in a ship’s electrical shop for a couple of months and attending a safety stand-down, a fireman gets shocked while helping a shipmate repair a bulkhead-mounted fan. By Lt. Robert M. Swain.

**Blind Leading the Blind**

An AT3 who isn’t PQS-qualified agrees to install a fan in a

squadron’s work center and gets zapped. By Lt. Edric Morgan.

**A Power Surge My Ticker Didn’t Need**

A Sailor rests his forearm on top of a transmitter while aligning its converter and is shocked by 1,000 volts of direct current. By ET2 Leroy Kirkland.

**Let Me Count the Violations**

A PO3 gets shocked while working inside an energized switchboard. By Lt. Tom Binner.

**What’s Biting the Hands That Feed You?**

Hazards in shipboard food-service areas, especially energized equipment, are taking a toll on the junior Sailors who work there. By CWO3 Tom Fayet.

**Sailor “Cooks” His Goose, Then Slices It**

Instead of calling an electrician’s mate to replace a blown fuse, an MS3 does it and ends up getting shocked by 440 volts and cutting a five-inch-long gash in his arm. By Ltjg. Daniel Morris.

**Thanks, You S.O.B.**

Rubber electrical gloves save the life of a seaman who is ordered to buff a ship’s mess decks. By Lt. John H. Parker.

**Departments**

**Editorial**

**What’s Biting the Hands That Feed You?**

*By EMCM(SW) Larry Solis,*

*Staff, ComNavAirLant,*

*and CWO3 Tom Fayet*

Electricity, that’s what. The food-service attendants (FSAs) who do much of the cleaning in their work area often have little shipboard experience. They may have even less time in the galley. In many cases, supervisors compound these problems by letting the FSAs work on and clean energized equipment.

Here are examples of why it’s important to look out for these junior shipmates:

**Will You Have It Light or Dark?**

An FSA was shocked while replacing a toaster in its mounting. Inspection revealed that one of four moving contactors had become welded to its fixed counterparts. These contactors moved each time someone used the front lever of the toaster. Pulling up the lever interrupted power to the heating elements. Then a metal retaining bracket for the moving contactors, which was connected to the operating lever by one screw, became misaligned. The result was a twisted retaining bracket that intermittently touched a live terminal, energizing the toaster’s metal casing. Inspection also showed the toaster’s grounding wire wasn’t connected to the ground inside the junction box that provided power to the unit.

**With Just the Flip of a Switch**

While washing utensils in a deep sink, an FSA turned on a garbage disposal and received an electrical shock. The problem was a missing rubber boot on the start button for the disposal.

**“I Barely Touched It”**

An FSA was cleaning behind a reefer when he brushed an exposed electrical wire that was touching the metal enclosure for a junction box. The result was an electrical shock.

**Should Have Ignored That Dust**

Seeing dust under the top of a pantry grill, an MS3 removed the splash guards between the griddle top and burner plates, then moved the burner plates to one side so she could clean. While reaching under the griddle with a soapy sponge, she touched electrical connections and was shocked. An investigation revealed that the MS3 didn’t tag out the griddle or secure power before removing parts. Even though she saw exposed wiring after removing the splash guards, she didn’t heed the electrical-safety training she had received.

To avoid similar hazards, you should consider these points:1

***** All plugged-in shipboard equipment requires electrical-safety checks. Although toasters fall under the provisions of mobile electrical equipment, which require annual checks, don’t omit initial safety checks when you install one. If electrician’s mates had connected the ground wire in the junction box in the first incident, the current flow from the broken toaster would have taken the path of least resistance. The ground conductor, instead of the FSA, would have taken the jolt.

***** All equipment using electrical power, including appliances in a galley and messdecks, must have their metallic frames connected to a ship’s ground.

***** Food-service electrical equipment, such as refrigerators and coffee makers, must have their own circuit and isolation transformer in a ship’s lighting-distribution system. When you plug these appliances into the ship’s existing 120-VAC receptacles, you can overload the circuit and create a fire hazard.

***** FSAs must be trained to follow tagout procedures and secure power to electrical equipment before cleaning it. Make sure they know where to find the electrical panels and switches that control galley equipment. Label all galley ranges, ovens, griddles, electrical switches, breakers, and controllers. Most  galley mishaps involve using wet or damp materials to clean energized electrical equipment. Galley supervisors should ask electrician’s mates to teach the FSAs about electrical hazards.

***** Because of the hazards in food-service areas, galley supervisors must train FSAs how to recognize and avoid such dangers as bare wires, missing protective covers and guards, and frayed cables. Don’t let them operate, maintain or clean galley equipment until they are qualified. Post operating instructions and precautions near each piece of galley equipment. Set the example; watch for obvious hazards and be alert for hidden ones, as well. If you find any problems, immediately place the equipment out of commission and report the hazards to the galley supervisor. Make sure qualified electrician’s mates do all electrical repairs.

*At the time the authors wrote this article, they were assigned to the Afloat Safety Programs Directorate at the Naval Safety Center.*

**For More Info...**

1 To avoid the problems described here, follow the guidance in PMS MIP 3000, Mil-STD-1310e (Navy); General Specifications for Overhaul of Surface Ships, Sections 651 and 320; NSTM, Chapter 300; and the NavOSH Program Manual for Forces Afloat (OpNavInst 5100.19C), with change 1, Chapters C19 and D13.

*Mishap reports about Sailors getting shocked while working in shipboard food-service areas are a dime a dozen. The tale that follows concerns a Sailor who learned the meaning of “double jeopardy.”*

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**Sailor "Cooks" His Goose, Then Slices It**

*By Ltjg. Daniel Morris*

We had come through a difficult restricted availability, a busy training cycle, and two trips out of country for port visits without submitting a single mishap report. We had had our share of cuts and scrapes, but nothing that required more than a few stitches. I was living every safety officer's dream.

During the second month of a six-month deployment, my dream came to an abrupt end. It began with a call to the pilot house at the end of a long midwatch. An MS3 had been baking for the morning meal and had cut himself. The ship's corpsman was calling to report the details for the deck-log entry. Although this situation seemed simple at first, it started to spiral downhill.

Investigators found that a cut wasn't the MS3's only problem. He also had been shocked. While replacing a fuse in one of the fans used to circulate air in the oven, he used a butter knife to open a panel containing this warning placard: "Disconnect power before opening." He then reached in with the knife and tried to reset what he thought was a circuit breaker. The knife touched a live contact, and the MS3 suddenly was "cooking" himself with 440 volts.

When he finally was able to jerk his hand free, the MS3 caught his wrist on the panel and sliced a five-inch-long gash from his forearm to the inside of his palm. Once the ship's corpsman was able to stop the bleeding, the OOD set emergency flight quarters, and the MS3 was taken to an aircraft carrier for more treatment.

This cruise was the MS3's last one, but instead of spending only one more month on active duty after the ship returned from its deployment, he had to stay for six months. The extension allowed him to complete physical therapy and regain the use of his hand.

This mishap was another example of what can happen when someone doesn't take the time to do a job right. All hands learned a valuable lesson that night. I think the real tragedy here is that it nearly always takes an incident like ours to remind us that we're constantly at war--against attitudes that can injure and kill.

*At the time the author wrote this article, he was assigned to USS*Merrill *(DD 976).*

*Now read about a food-service attendant whose life was spared because a lieutenant made him don a pair of electrical-grade rubber gloves before he buffed the mess decks.*

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**Thanks, You S.O.B.**

*By Lt. John H. Parker*

“Go get some rubber electrical gloves on before you plug in that buffer,” I admonished a seaman, who was getting ready to scrub the messdecks.

I then chastised the messdecks MAA, a BM1 who was supposed to be supervising the seaman. “Why aren’t you enforcing the safety rules?” I asked. “Don’t let me see any more food-service attendants using buffers or any other electrical equipment without the proper PPE, or you’ll be answering to me.”

Looking a little perplexed, the BM1 blurted out, “Sir, you give me too much to do, with too few people and too little time. On top of all that, you expect me to be an S.O.B. and make sure the troops follow every ridiculous, little safety rule.”

“You don’t have to be the only S.O.B.,” I told the BM1. “I’ll be one, too. You tell them it’s you, me and naval directives that are making them follow all these ‘ridiculous, little safety rules.’ But I’d better not catch anyone violating them, or you and that person will be explaining your actions to me. Do we understand each other?”

“Yes, sir,” replied the BM1.

With that, I was off to the supply office. About 10 minutes later, I heard, “Duty corpsman to the messdecks! Duty corpsman to the messdecks!” over the 1MC. I ran out of the supply office and forward to the messdecks, where I found a crowd gathered around the seaman I had encountered earlier. He was unconscious on the deck. I could smell burnt rubber, and I saw some pale, blue-white smoke.

Seconds later, the duty corpsman arrived. As he moved the crowd back and started to work on the motionless seaman, the corpsman asked what had happened.

“He just started buffing the wet deck when a huge arc of electricity shot out of the buffer, and he just fell down,” said the shaken BM1.

In about six minutes, the seaman came to, and an ambulance took him to a medical center. Doctors released him two days later, fit for duty. The medical report they sent to the ship said the seaman had received a severe electrical shock. Because he was wearing electrical-safety gloves, though, most of the current had not entered his body.

A year after that incident occurred, the seaman and his wife asked me to be the godfather of their daughter. “Why me?” I asked.

“Well, sir,” the seaman replied, “if I may be so direct, you’re the S.O.B. who saved my life.”

All I could think of that day was, “Yes, safety rules can seem like a pain, but if enforcing them makes a person an S.O.B., then you can call me that anytime.”

**Recipe for a Shock**

*By GSCM(SW) Richard Eckenroth,*

*Staff, ComNavSeaSysCom*

It won’t make Betty Crocker’s collection of world-famous recipes, but here’s a list of the basic ingredients for cooking up yet another electrical-mishap report:

· Any class of ship

· One maintenance person (the more junior, the better)

· One maintenance action (any job, any priority)

· A small amount of experience

· Too little training

· Spotty supervision

· One piece of energized equipment

Stir in a little urgency and a pinch of overconfidence, blending them with a shortcut or two. Note: Tagouts and PPE are not part of this recipe. Start the job and give yourself time, write the lessons learned, and hold training--but don’t change the recipe. For spectacular results, use this recipe on energized switchboards, load centers, and high-voltage equipment. Occasional replacement of maintenance personnel will be required.

*At the time the author wrote this article, he was assigned to the Afloat Safety Programs Directorate at the Naval Safety Center.*

*The stories of two Sailors who died in electrical mishaps follow.*

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**Deadly Shipmate Strikes Again**

*By ETCS(SW) Dave Williamson, USN(Ret.)*

An ET2 had been assigned an annual PMS check to verify voltages and waveforms on a signal-data converter in radio. The MRC showed the job should take a half-hour to complete. Three hours after the ET2 started the job, an RM1 found him dead on the deck in front of the converter. Medical personnel reported finding two small burn marks on the back of the victim’s right hand.

The ET2’s work-center supervisor knew he had been having problems with the PMS check. Most of the check was to measure 120 volts direct current (VDC) at test points on the front panel. The ET2 reported, however, he was reading only 30 VDC. A caution on the MRC alerted users about a potential problem. According to that note, the metal, spring-loaded caps covering the external points could short the test point to ground if allowed to touch the test-equipment probe.

The ET2 and his leading chief had discussed this caution before the PMS check started. Apparently, though, they didn’t talk about it again when the ET2 reported the low-voltage reading. They also didn’t decide how to isolate the problem.

Fifteen minutes before the RM1 found the victim, another shipmate reported seeing the ET2 at work. At that time, no equipment covers were open or removed. A witness, however, said the front panel of the signal-data converter was removed when he entered radio. The top cover of an ancillary power supply on a shelf above the converter also was open. Both were de-energized, but the circuit breakers on the power panel still were on. Three leads, which were inputs from the power supply, inside the converter had been disconnected from a terminal board in the equipment.

How was the victim electrocuted? One theory is he may have accidentally touched charged capacitor leads. Immediately after the mishap, testing by ship’s force showed a capacitor was retaining its charge up to five minutes. Mishap investigators, however, could not duplicate this condition or the original problem of low voltage at the test point.

Another theory is the ET2 may have touched 115 volts. Even with the power switches off in the front panel, energized circuit breakers on the bulkhead supply 115 VAC on one side of the on-off switch. There’s also 115 VAC present on a terminal board inside the equipment.

Another possibility is the ET2 may have brushed his hand against one or more of the three disconnected leads, then turned off the power supply before his heart stopped.

Fatigue may have affected the victim mentally and physically. He may have had as little as five hours of sleep during the preceding 48 hours. Two days before this mishap, the victim was on liberty in a foreign port, where he reportedly was drinking heavily. He had only one hour of sleep before reporting to the ship for duty the next day. On his duty day, shipmates observed him working in radio until about 2300. He then had the 0400-0800 watch the next day--the day of the mishap. The OOD had counseled the ET2 for being sluggish and not paying attention on watch. At quarters, his leading chief had noticed that he looked drowsy. Although most Sailors don’t like to shirk duty, they are responsible for telling their supervisors when they are too tired to do their jobs.

A warning placard wasn’t posted, showing that multiple power sources (115 volts and the ancillary power supply) fed the signal-data converter. This discrepancy, however, didn’t relieve the ET2 from his obligations. Before starting to work, maintenance people should study schematics and learn all sources of input power, capacitors that store voltage, high-voltage components, and any other hazards. Investigation also revealed that the ET2 was using the technical manual for an earlier model of the power supply involved. This mistake could have confused his troubleshooting.

Maintenance people must discharge all capacitors and use a voltage tester to verify all conductors are de-energized before working on a circuit. The fact that investigators didn’t find electrical-grade rubber gloves or a shorting probe at the scene indicates the victim neglected this critical procedure. Electrical gloves are required anytime you are exposed to more than 30 volts.1 If it’s too cumbersome to wear electrical gloves on both hands, then you must wear a glove on your free hand. Because all conductors are assumed to be live until tested, the ET2 should have worn electrical gloves to make those measurements.

The ET2 departed from troubleshooting procedures in the technical manual but didn’t notify his chain of command he was doing so. The manual does not call for disconnecting the three input leads from the power supply. Before making this mistake, the victim should have stopped and discussed his plan with his supervisors. He should have found out if his proposed procedure was safe and if it would work.

# Measuring voltage with the leads disconnected required the CO’s permission. This permission is necessary anytime you work on energized equipment and don’t follow PMS or troubleshooting procedures in the technical manual. Besides involving senior technicians, asking permission also alerts the CO to a situation that places personnel at increased risk. The CO weighs the risk against the necessity and decides if the possible gains outweigh the increased risk. The important point to remember is that only the CO can make that decision.

If the ET2 planned to troubleshoot energized equipment, he also needed a safety observer who could give first aid and secure power. He was obligated to keep his supervisors informed and to ask for help if he needed it. Don’t be afraid to demand that procedures be followed. If you know that a safety observer, a pair of electrical gloves, or a shorting probe is required, get them.

Meanwhile, supervisors must take an active part in all operations. In this case, the supervisor knew the ET2 was having problems. They even discussed the problems but didn’t decide what to do. In hindsight, the supervisor probably should have assigned someone to help the ET2 when he started having problems completing a 30-minute PMS check. Instead, three hours passed before the RM1 found the victim’s body.

*The author wrote this article while he was assigned to the Afloat Safety Programs Directorate at the Naval Safety Center.*

**For More Info...**

1 The requirements for wearing electrical gloves are outlined in NSTM, Chapter 300, Section 2.

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**Twist of Fate**

*By CWO3 Tom Fayet*

An MM2 planned to use a mobile air compressor to repair a ship’s valve. Using a metal-cased electrical-plug adapter, he joined the compressor cable to a 75-foot extension cord, which was connected to a 440-volt receptacle. There was a problem, though: The compressor wouldn’t start.

In his effort to find the cause, the MM2 grabbed the adapter and twisted it to verify a good connection. This mistake proved to be his last. For two or three seconds, 440 volts of electricity coursed through the victim’s body. He then dropped the adapter, staggered backward, and fell against a platform.

When shipmates reached the MM2, he had stopped breathing and had no pulse, so they immediately started CPR. They also called medical-emergency-response personnel, who tried unsuccessfully to defibrillate him. An ambulance took the MM2 to a hospital where doctors pronounced him dead.

# Blatant disregard for precautions led to this tragedy. For example, the metal-plug adapter he was using is prohibited aboard ship. Personnel in the ship’s supply department probably never saw it. If they had, they would have turned it over to the electrical-tool-issue room for inspection before issue. Supply-department personnel pay particular attention to items that Sailors get through open purchase or from ServMart.

If the metal adapter hadn’t killed the MM2, the extension cord could have. Technicians who made up this cord obviously ignored regulations. It always has been illegal to jury-rig equipment (e.g., make up a three-conductor cable for a three-phase system without a fourth conductor for the ground connection). The technicians compounded their blunder by using cable that didn’t meet the amperage requirement of the compressor. In a matter of time, the cord would have burned and could have hurt someone.

None of these problems, however, would have mattered if the correct players had been involved from the beginning. For example, the people in the electrical-tool-issue room didn’t get a chance to check the air compressor when it arrived--as requirements dictate. If so, they wouldn’t have made an extension cord for it. Instead, they would have replaced the unit’s original cord with one not more than 100 feet long and capable of handling the unit’s amperage draw.

This action would have removed the other deathtrap: the lack of a grounding conductor on the portable compressor. Requirements are specific about tools or devices that need to be grounded. When the portable cord supplied with these items doesn’t include the necessary extra conductor, personnel must not use the equipment until it is rewired correctly.

The twisting of the “hot” adapter simply completed the recipe for disaster. As it turned out, one phase of the compressor plug touched the outer case of the metal adapter when the victim twisted it, which provided a current path through him to ground.

The victim might be alive today if he had followed the “so simple they sound stupid” procedures for connecting and disconnecting electrical equipment. According to these rules, you always connect the cord of portable electrical equipment to an extension cord before you stick the cord into an energized receptacle. Always unplug the extension cord from the energized receptacle before unplugging the equipment from the extension cord.

# After I had read about this mishap, I couldn’t help wondering what happened to the concept of letting only trained electrician’s mates and technicians troubleshoot and repair electrical and electronic equipment. More importantly, why hadn’t the victim’s supervisors noticed at least one of the many glaring safety violations? At least four of 15 general precautions were ignored. The references1 say to report any unsafe equipment or material condition. This system allows trained personnel to fix problems before they hurt or kill someone. The supervisors should have made sure all the electrical and electronic equipment in the space met electrical-safety requirements.

I also questioned what kind of training the workers must have been getting. For training to be effective, it must be held regularly. Considering all the violations that jumped out at me while reading this tragic account, it seems evident personnel weren’t spending much time studying electrical-safety rules.

*At the time the author wrote this article, he was assigned to the Afloat Safety Programs Directorate at the Naval Safety Center.*

**For More Info...**

1 Electrical-safety information is found in NSTM, Chapter 300, Section 2; NavOSH Program Manual for Forces Afloat (OpNavInst 5100.19C), with change 1, Chapters B7, C9 and D5; and Standard Organization and Regulations Manual of the U.S. Navy (OpNavInst 3120.32C), Paragraph 630.17.

**Who Takes Precautions Seriously?**

*By Lt. Robert Swain, Jr.*

“Certainly not Fireman Smith,” you may say. This Sailor was eager to become an electrician’s mate, so he spent a couple of months in the electrical shop getting practical experience for the next advancement exam. When his ship held a safety stand-down, he had a front-row seat for the electrical-safety lecture.

A week after the stand-down, someone called the electrical shop about a broken bulkhead-mounted fan in the junior officers’ bunkroom. Fireman Smith volunteered to help an electrician’s mate do the work.

Upon entering the space, the two Sailors noticed the room was hot, and condensation covered everything. They began looking for obvious problems. As the electrician’s mate turned to find the power switch, FN Smith tilted the fan for a better look. The electrician’s mate heard a faint yelp and saw FN Smith jerk his hand away from the fan.

Why did this mishap occur? The instructor for the electrical-safety lecture at the stand-down had covered such situations. Did FN Smith’s mishap mean the stand-down was ineffective or something was missing?

No.

A person doesn’t start taking precautions seriously just because he attends a lecture or takes a course. The key is the person’s supervisor, who should start discussing precautions for a particular job during the planning phase. This action gets everybody thinking about priorities. Allow enough time to set up controls, tag out the equipment, and do maintenance with a qualified safety observer on station, if required.

Supervisors also should review checklists for key items. You may find that your own checklist overlooks important information. If you have to develop a new list of precautions, start with the technical manuals. Pay particular attention to all warnings and precautions listed for each job. Your safety petty officer also can be a valuable resource. Before publishing a new safety checklist, let the safety officer look at it because his training may reveal areas no one else considered.

Maintenance people stock their tool kits with all the tools they need. In similar fashion, supervisors should ensure workers have all the safety tools (e.g., precautions and warnings). Review the checklist with workers before they leave the shop; maintenance people have to know what must be done before starting a job. Emphasize any special concerns that you have and give the workers time to ask questions.

Monitor progress closely. You’ll only get what you inspect. Don’t let cumbersome electrical-safety gloves, bulky respiratory equipment, and uncomfortable faceshields find their way into a pile in the corner. Insist on everyone wearing the required protective gear.

Impress on workers that they must follow the procedures developed in planning throughout the project. Looking the other way sends a strong message that speaks much louder than words. Consistency and dedication will be rewarded.

Any mishap that causes an injury or death is one we cannot afford. Set the right example, and others will develop the same habits.

*At the time the author wrote this article, he was assigned to USS*Antietam*(CG 54).*

*The story that follows describes another Sailor’s encounter with an energized shipboard fan.*

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# Blind Leading the Blind

## By Lt. Edric Morgan

Despite efforts to promote electrical safety in the fleet, some Sailors still don’t realize the hazards involved with power-distribution systems aboard Navy ships. Supervisors sometimes add to the problem by failing to provide training. Here’s the story of a Sailor who suffered the consequences:

On the request of his supervisor, an AT3 started hard-wiring a fan into a squadron’s work center aboard ship. Unfortunately, he didn’t tag out the 115-volt circuit or de-energize it. Instead, he climbed a ladder, removed the cover plate from the junction box, and began connecting the leads. He was hooking up a hot lead when he got shocked. As he crumpled against the ladder, a PO3 and an AA rushed to help him down.

When corpsmen arrived on the scene, the AT3 had no pulse. His breathing was shallow and slow. The medical people diagnosed cardiac arrest and started CPR. Using a portable life pack, they defibrillated the victim’s heart twice before it returned to normal. Then they stabilized him and moved him to medical for more treatment and observation.

After this mishap, investigators checked the training records of 124 squadron personnel to see what electrical-safety classes they had attended. Only six of the records revealed shipboard training. Another 57 showed the people had attended some training ashore. The remaining 61 records had no entries for any electrical-safety training. No one had received this training during indoctrination. Finally, the records showed no one had attended tagout training. The victim in this mishap had some shore and aircraft electrical-safety training but no shipboard or tagout training.

The AT3 wasn’t PQS-qualified as a shipboard electrician.

Squadron personnel had sent a memo to E division five days before this mishap, asking them to install the fan. However, they hadn’t submitted a work request.

The supervisor, who drafted the memo to E division, got the AT3 to install the fan because he didn’t feel E division would respond quickly enough. He and other supervisors also knew the AT3 had installed two fans in another space. The PR1 didn’t know the AT3 wasn’t qualified to work on shipboard-electrical circuits. The PR1 didn’t supervise the installation.

To avoid similar problems, make sure everyone who works with shipboard-electrical systems is PQS-qualified and follows all precautions and requirements. Ship’s force and embarked squadron and detachment personnel must establish and follow the procedures for electrical repairs and installations. All hands must follow the guidance in the ship’s tagout instruction.

*At the time the author wrote this article, he was assigned to the Afloat Safety Programs Directorate at the Naval Safety Center.*

**Don’t Overload Your Outlets**

*By JOSN Sarah Deal,*

*USS*Dwight D. Eisenhower *(CVN 69)*

We have a problem aboard *Ike*: The crew jams the 115-volt wall outlets with too many hair dryers, CD players, computers, coffee pots, and other personal items. When the outlets are full, the crew gets a surge suppressor and fills all of its outlets. Then comes another surge suppressor.

What happens next is no mystery; a fuse blows. “The receptacles in *Ike* are only capable of safely accepting thirteen amps. If you plug in an item or several small items that draw more than thirteen amps, the fuse blows,” says EMC(SW) Charles Spagnuolo.

Perhaps you have the same situation on your ship. According to safety surveys, many ships do. The problem aboard *Ike* is that the ship was designed in the ‘60s, when there was no idea how far the field of electrical distribution would advance. Nearly everything on *Ike* runs off 110-to-440-volt receptacles. There are six or seven receptacles running on each electrical line throughout the ship to meet the maximum-draw requirement of 13 amps.

Outlets in homes are built with a hot lead and a neutral lead. Shipboard outlets, on the other hand, have two hot leads, and they are not protected against a power surge. Apart from the hazard caused by personal items that aren’t safety checked, there is a problem with people overloading office receptacles with too much equipment. As more and more electrically powered equipment is used in ships, requests for more receptacles continue to flow into the electrical officer. “To install more receptacles,” Chief Spagnuolo explained, “we have to add more power panels or locate a panel with room for the extra lines.”

# Putting in higher-amp fuses is not an option! What Ike crewmen don’t seem to understand is that if too much current passes through a receptacle, it can heat the wires enough to start a fire.1

Chief Spagnuolo often finds surge suppressors plugged into each other. “In some cases, they aren’t even the approved model2,” he said. Besides using the wrong surge suppressors, some crewmen take it upon themselves to increase the fuse’s amperage.

The solution to these problems starts with Sailors leaving their hot plates, air conditioners, and other unauthorized items at home. They also need to get personal gear safety checked. Here are some more tips:

· Turn off all unnecessary equipment before using a buffer because the power surge from a buffer can blow a fuse.3 

· Use the approved surge suppressor only for office equipment.

As Chief Spagnuolo pointed out, *Ike*’s electrician’s mates have more things to do than just replace blown fuses. “Instead of getting the usual five or six trouble calls a day for fuses, we’re getting about thirty,” he said.

**For More Info...**

1 Paragraph 300-2.7.3.5 of NSTM 300 provides a formula for calculating the number of receptacles that can be on one circuit. Meanwhile, the General Specifications for Overhaul of Surface Ships lists the requirements and limits on the number of receptacles in a space.

2 The stock number for the approved surge suppressor is NSN 6510-01-362-7192.

3 GSO, Section 303, states that F09B15VAS-type fuses, which blow slowly, are to be used in shipboard receptacle circuits.

**A Power Surge My Ticker Didn’t Need**

*By ET2 Leroy Kirkland,*

*USS*Juneau *(LPD 10)*

As I placed a non-metallic tweaker on the transmitter’s potentiometer, I used the DC-to-DC converter for stability. That’s what the procedures in the technical manual called for, and I was following them closely, because working on energized equipment is delicate business. In fact, this particular job--aligning the converter--is so delicate it’s impractical to wear electrical-safety gloves.

I wish I could tell you I finished this task without a problem. However, I made a mistake. For just a moment, my attention wandered, and I absent-mindedly rested my left forearm on top of the transmitter. Because the cover was made of fiberglass, it flexed downward under the weight of my arm--far enough to cause a high-voltage arc from the power-amplifier-tube plate under it. Immediately, 1,000 volts of direct current shocked me, burning the tip of the finger I was using for stability.

# A safety observer alertly secured power to the equipment and took me to medical, where corpsmen hooked me up for an electrocardiogram, for the rest of the workday.

What did I learn from this encounter?

· Pay attention to what you touch, especially when working on energized equipment.

· Safety observers can be lifesavers.

· Know your equipment, as well as all the potential shock hazards for a job.

After this mishap, the electronics-material officer had us cut a piece of rubber matting to fit around the transmitter to reduce the chance of another shock.

**Top 10 Reasons Why Sailors Get Zapped**

*By EMC(SW) Carl Henry,*

*USS*Nicholson*(DD 982)*

Think of electricity as a powerful and dangerous tool, held in check by a triangle made up of training, QA and supervision. If one side of the triangle fails, electrical hazards eventually will run out of control. Here are the 10 most common electrical problems I find during surface-ship-safety surveys:

# 1. Many electrical circuits are overfused or underfused.1 The next time you have to replace fuses in a fuse box, why not do the job right? You have to tag out the fuse box anyway (unless vital equipment is involved), so don’t just replace the fuses. Instead, take an extra minute before you start to work and make sure the wiring diagram is OK. If you find problems, submit them up the chain of command. Something that I find amazing is the number of man-hours shipboard personnel spend ensuring all fuses match the requirements listed on label plates (3-amp label = 3-amp fuse), even after the crew has done PMS.2

**2. Fuses with the wrong ferrule material (brass or nickel, instead of silver) are installed.**3 I was shocked to find one ship that still had brass-ferruled fuses in the 115-volt lighting circuits. Instead of being in a fuse box, they should have been in a museum. In case you didn’t know, brass-ferruled fuses haven’t been authorized since Nov. 5, 1991.

# 3. Megger test holes are not plugged on the power-supply circuit breakers of manual-bus transfers.4 Type-commander messages5 make it clear: Power panels and manual-bus transfers must have the megger holes covered.

**4. Fuse boxes are not labeled correctly with the circuit controlling the phases or polarities and the fuse-ampere ratings.**6 When I survey ships, it doesn’t take long to find fuse boxes incorrectly labeled with grease pencils. Some ships make the mistake of writing directions on tape about what circuit is involved. For ships with new installations (after 1996), and whose fuses boxes are three-phased input and single-phased output, the single-phased loads are required to show which phases (e.g., AB, BC, CA) have a load. This requirement makes it easier to maintain a better load distribution for the power system.

# 5. Fuse boxes and distribution panels aren’t maintained.7 How many power panels aboard your ship have only one or two screws holding the cover in place? Did you ever wonder what happened to all the other screws? As I walk around ships, looking into fuse boxes, I find many that are missing hardware, with no supporting documentation to purchase replacements. I also find circuits that have two sets of conductors coming from a single set of fuses (in one case, neither was labeled). In some cases, I find the missing wingnuts from covers inside fuse boxes, along with extra fuses. Investigation usually reveals that maintenance people are looking at the boxes; they just aren’t trying to fix any of the problems. They also aren’t taking the time to put all the screws back in the covers.

# 6. Dead-ended cables aren’t identified and isolated correctly.8 About every 18 months, IMA people or ship’s force inspect cableways. Still, we find a lot of problems during our surveys; the safety petty officers should find these problems when they do the compartment inspection and PMS.9 In one case, we found the end of a cable hanging merely inches above the scullery dishwasher being used by a food-service attendant. There was just one problem: The cable was live! Another time, we found the end of a live cable hanging about shoulder height in a maintenance office. No one had taken the time to report it.

# 7. Shore-power cables aren’t roped off and protected.10 A Sailor was burned severely on his body and arms when a cable failed, and the resulting fire engulfed him. Cables need to be roped off from traffic. Because they’re left out in the weather, check them periodically for damage from the elements.

**8. Electrical repairs lack quality assurance.**11 Junior Sailors are doing too much maintenance and daily repairs with too little involvement of work-center supervisors, LPOs and CPOs. We have to make the junior people aware of the hazards so they can identify them later.

# 9. Accountability for electrical-tool issue is poor.12 When tool-issue operators go around a ship looking for electrical gear, divisions usually have one or two pieces missing. These pieces seldom are found, even after the parent division searches for them. Because the equipment is lost, a tool-issue custodian fills out the necessary paperwork to delete the item from the EGL. Months later, however, often when an assist team is aboard, someone finds the gear and uses it. The team, of course, checks and finds the PMS on the item is delinquent, which sends everyone into a panic.

# 10. Galley equipment is in various stages of disrepair.13 How many people will have to get shocked before we finally understand how dangerous a galley is? I remember an incident that happened as I was reporting aboard a ship for duty. A fellow chief was taking me to the CPO mess when I saw an HTC using a knife to get his toast from a toaster. I stopped him, and he explained the toaster spring had broken. That shock-waiting-to-happen, though, was no worse than some I’ve read about in mishap reports during my tour at the Naval Safety Center. For example, an MS was shocked when he opened a Gaylord hood’s control cabinet (the cabinet screw was missing) to clean its electrical components. How about the electrician’s mate who didn’t secure the grease trap on a griddle? When an MS used the griddle, he was shocked because the trap chafed the wiring.

# With all the emphasis placed on electrical safety in the fleet for so many years, doesn’t it seem like we should have learned more than our track record shows? I checked two years’ worth of post-survey comment sheets prepared by my predecessors, then compared them with mine, and found many similarities. I also found many of the same similarities when I compared my findings with those of InSurv and the Engineering Training Group. We have to keep electrical safety on the front burner every day, not just when we’re getting ready for the scrutiny of an assessment team.

*The author was assigned to the Afloat Safety Programs Directorate at the Naval Safety Center when he wrote this article.*

**For** More Info...

1 Refer to Paragraph 300-2.5.4 of NSTM 300 for guidance about fusing electrical circuits.

2 PMS 3301/005, 18M-1 outlines requirements for making sure that installed fuses match the sizes listed on label plates.

3 Check Paragraph 300-2.5.4.1 of NSTM 300 for details about using silver-ferruled fuses.

4 Refer to Mil-P-23928D and ComNavSeaSysCom message DTG 230319Z Nov 98 (NOTAL) for information about plugging megger test holes.

# 5 Guidance on plugging megger test holes also is contained in ComNavSurfLant message DTG 112205Z Dec 98 (NOTAL) and ComNavSurfPac messages DTG 150124Z Dec 98 (NOTAL) and 080504Z Jan 99 (NOTAL).

6 Refer to General Specifications for Overhaul of Surface Ships, Sections 305e and 602g, for details about labeling fuse boxes.

7 MIP 3301/005 provides guidance on the correct maintenance for fuse boxes and distribution panels.

8 Paragraph 300-2.5 of NSTM 300 and General Specifications for Overhaul of Surface Ships, Section 305F, describe the proper ways to identify and isolate dead-ended cables.

9 PMS 6641/4, S-3R describes the procedures for doing the compartment-check-off-list maintenance.

10 General Specifications for Overhaul of Surface Ships, Section 332d, outlines procedures for roping off and protecting shore-power cables.

11 Paragraph 300-2.1.4 of NSTM 300 discusses QA for electrical repairs.

12 NavOSH Program Manual for Forces Afloat (OpNavInst 5100.19C), with change 1, Paragraph B0704, contains guidance on tool-issue accountability.

13 Paragraph 300-2.5 of NSTM 300 and NavOSH Program Manual for Forces Afloat (OpNavInst 5100.19C), with change 1, Chapters C19 and D13, contain guidance about the dangers of galley equipment.

# “Is This Cable Live?”

## By Ken Testorff,

## Naval Safety Center

That’s the question an MMFN asked an EM3 while they were cleaning a berthing compartment. The MMFN had seen the loose cable in the overhead.

The EM3 said he assumed the cable was dead. “It’s probably just left over from an old ship’s entertainment system,” he explained. He proved otherwise, however, when he grabbed the cable to move it. This mistake knocked him to the deck.

The chain of events leading to this mishap started when workers replaced a scullery machine. The replacement didn’t need one of the pumps the original machine required. As a result, the workers disconnected and cut off a 440-volt cable flush with a stuffing tube in the deck. However, they didn’t mark the cable, tag out the motor controller, or remove the obsolete pump’s label from the fuse box.

Later, while removing the scullery’s terrazzo deck, a contractor cracked the stuffing tube at the deck. After he finished the new deck, ship’s personnel found water leaking into a berthing compartment below the scullery through the cracked stuffing tube. Workers pulled the dead-end cable through the tube into the berthing compartment and put it in the overhead. Then they sealed the stuffing tube. An electrician’s mate tested the cable and found it still was energized, but he didn’t do anything about the hazard.

A week later, the EM3 learned about the energized cable the hard way. After he got up off the deck, he told the MMFN not to let anyone enter the area and left to get medical attention. En route to sick bay, he reported the hazard.

After this mishap, electrician’s mates traced the dead-end cable back through an energized controller, pulled the fuses, and tested the cable again. They also removed the controller, the cable and the fuse-box label.

Here are some more tales about Sailors and their encounters with live cables they thought were dead.

**Beware Alternatives**

A GSM2 was pulling a dead-end cable when it got stuck on an angle iron in the overhead. Instead of trying to free the tangled mess, he decided to cut the cable with a pair of uninsulated lagging pliers. As he made the first cut, he was shocked badly enough to make him drop the pliers. He went to sick bay, where a corpsman found him fit for duty. Why did this mishap occur? Because the GSM2 **assumed** the cable was dead, even though it didn’t have a tag or cap on the dead end as required.1

**A Case of Mistaken Identity**

A Sailor and his co-worker had to remove a dead-end cable from a ship’s pipe shop. Electrician’s mates had located and de-energized the cable. When the two Sailors found what they thought was the correct cable, they picked it up and tried to locate its source. Moments later, a piece of electrical tape covering the bare connector end came off in one Sailor’s hand, giving him a 440-volt shock.

As any of these victims will tell you, it’s smarter taking a few extra minutes to make sure a cable really is dead, rather than feeling its live wrath.

*The author’s e-mail address is ktestorf@safecen.navy.mil.*

**For More Info...**

1 The requirement for dead-ending cables is spelled out in the NSTM, Chapter 300.

**Electricity Is Everywhere...**

*By ET1 Fred G. Bell,*

*TacTraGruLant, Dam Neck*

And you could be the next victim. As a young third class, I was shocked by more than 300 volts alternating current (VAC), which threw me across a space and burned my hand. I’ve also heard about shipboard Sailors getting zapped by 440 VAC, and I know that some electronics gear contains more than 6,000 volts direct current (VDC). But fewer people die from this impressive-sounding voltage than from the common 115 volts found in a wall socket.

What many people don’t realize is that it’s the current (measured in amperes), not the voltage, that’s dangerous. Most of us have seen fuses and circuit breakers rated at 10 to 25 amperes. You might conclude that one ampere is nothing, right? 

**Wrong!**

At 1/1,000th ampere, you feel a tingling sensation. At 1/100th ampere, you get a hard kick. One-tenth ampere will make your muscles go rigid, and if that includes your heart muscle, you’re dead!

These figures apply to a person whose body is dry. When you’re wet, as little as 30 volts can cause enough current flow through your body to stop your heart.

Now the average Sailor may say, “That’s great information to know if you’re an electrician’s mate or an electronics technician, but what does it have to do with me?” Do you have a stereo? Do you ever use an electric grinder to prepare a bulkhead for painting or a buffer to make the deck shine? At the same time, consider that you serve aboard a steel ship surrounded by salt water--two excellent conductors of electricity.

Here are some precautions that will keep you from getting zapped:

Navy equipment that is not hard-wired to a power source must have a three-prong plug. The third prong is the ground lead, which connects all exposed metal parts of the device to the hull of the ship. All three prongs should be clean and free of corrosion. Only two kinds of plugs are acceptable aboard ship: a molded plug installed by the manufacturer, or a plug that’s imprinted “hospital grade.” Get rid of any plugs with chips, cracks or exposed metal.

Examine the cord. The only thing keeping the voltage (and current) from you is the insulation. If it’s cracked, there’s a strong chance that grabbing the cord in that spot will bounce you off the nearest bulkhead. Finally, check where the cord enters the equipment. The cord must be seated firmly within the equipment case.

Because water is an excellent conductor of electricity, it’s a bad idea to work with electricity in the rain, while standing on moist surfaces, or in any condition where your body becomes wet (including sweat). Wear approved rubber gloves, and don’t run cords through puddles of water.

Don’t try to repair electrical or electronic equipment. Leave that task to the professionals.

Make sure all electrical equipment has a tag attached to the cord, showing the date of the last safety check and stating how often the equipment has to be checked. If the device is past due for a check, don’t use it.

Authorized personal electrical and electronic gear requires a safety check every six months by a qualified electrician’s mate or electronics technician. Unauthorized personal items don’t even belong aboard ship. Among these items are fans, portable extension cords and extension lights, high-intensity and reading lamps, electric blankets, and heating pads.1

Devices such as radios and tape players that will be used only on battery power also should be checked. Any input for AC power should be disconnected. Never use any of these items in the shower or head.

Every day in the fleet, at least one Sailor gets shocked--usually minor, sometimes major. If you happen to find someone who has been electrocuted, don’t touch him until you’re sure he isn’t attached to a live circuit. Otherwise, you could become the next casualty.2

*At the time the author wrote this article, he was assigned to USS*John F. Kennedy *(CV 67).*

**For More Info...**

1 Refer to the NSTM, Chapter 300, for a complete list of personal electrical items that are prohibited from shipboard use.

2 NSTM 300-2.1.3 tells you the procedures for removing victims of electrical shock from the source.

**Shock Injuries Not Always Just Skin-Deep**

*By Capt. James Fraser,*

*Naval Safety Center*

Mishaps involving electricity kill more than 1,000 people a year in the United States. Countless thousands are injured, including hundreds of Sailors.

If you get shocked, the seriousness of your injury depends on the type of voltage involved, the resistance of your body at the point of contact, the path of the current through your body, and how long the current flows through your body.

Volt for volt, direct current (DC) is less damaging than alternating current (AC). The former often produces muscle contractions that knock the victim away from the current source. However, alternating current can cause victims to clench their hands, which fixes them to the current source. Consequently, AC is considered to be about three times more dangerous than DC.

Victims of electrical shock may immediately show the effects. Common signs include a tingling sensation, burn marks or an irregular heartbeat. In other cases, though, these effects are delayed.

For example, a food-service attendant (FSA) was cleaning a drink machine and nearby surfaces with a wet sponge. A bulkhead behind the beverage-line equipment had been removed a few days before. Cables and junction boxes were hanging from the overhead at eye level. While the FSA was wiping one of the cables, water from the sponge ran into a 25-amp, 440-volt, circuit-connection box, causing an electrical shock.

He went to sick bay, complaining of sore hands. A doctor treated and released him, but he returned two hours later, saying his arms and hands were bothering him. During this exam, the doctor found an irregular heartbeat and ordered an ambulance crew to take the FSA to a medical center for follow-up treatment. Upon release a few hours later, he returned to full duty.

Anytime an electrical shock triggers an abnormal heartbeat, the victim can suffer a heart attack, and CPR may be necessary to save the victim’s life. Alternating current of 60Hz at 110 to 220 volts traveling across a person’s chest for less than one second can trigger a heart attack. You find this kind of current in buffers, tools and personal appliances, as well as galley equipment, such as toasters, grills and deep-fat fryers.

Electrical shocks can burn the body at the point of contact. A burn mark also may appear at the exit (or grounding) point. Here are the stories of two Sailors who suffered such injuries and required treatment:

***** A PO2 suffered second-degree burns to his arm when he was shocked by 440 volts during PMS checks. To complete the job, he had to reach deep inside an energized cabinet. He wore the prescribed PPE (1,000-volt electrical gloves), but much of his arm was exposed because the gloves were too short. After this mishap, suggestions surfaced to redesign the cabinet, to design an electrically insulated tool for the job, or to design gloves that would offer more protection.

***** A PO1 was helping a tech rep troubleshoot a casualty in a piece of equipment. While removing part of the unit, the PO1 became concerned that cables attached to it might get entangled. He went to the back of the unit to guide the cables. During this process, his hand must have touched (although he swears it didn’t) a 440-volt, input-power terminal, which shocked him. At sick bay, doctors found a third-degree burn that began on the bottom of his hand and ended as a red mark on his shoulder. They took him to a clinic where he received an EKG and two intravenous injections. Doctors diagnosed his injury as a superficial surface burn and returned him to full duty.

External injuries aren’t the only damage that occurs to the body during an electrical shock. In most cases, tissues inside the body also are hurt as the current flows along nerves and blood vessels, which, like muscles, are much more sensitive to electrical-shock injuries than other tissues are.

Electrical current can “cook” muscles in parts of your body far removed from the site of the injury; the amount of damage is proportional to how resistant the tissue is. Bone is a poor conductor but retains heat a long time, often causing severe damage to deep tissues, while the surrounding layers are less affected. Because of all the harmful substances produced when muscle is cooked and destroyed, victims are at risk of kidney failure. Shock victims also can injure muscles and bones as a result of the violent contraction of muscles during the shock. If victims are working on platforms, they can injure themselves when they fall.

These unexpected and invisible injuries are why victims of electrical shock always should get hustled to medical. They may require a period of close observation in a hospital.

*Capt. Fraser is head of the aeromedical division of the Aviation Safety Programs Directorate at the Naval Safety Center. His e-mail address is jfraser@safecen.navy.mil.*

**Zap Puts More Zip in Your Snap**

*By Ken Testorff,*

*Naval Safety Center*

What will snap a Marine to attention (or put him at parade rest) faster than any drill instructor (DI) can, regardless of how much bite the DI has in his bark? Electricity.

For example, a Marine was helping a ship's electrician's mates by replacing a burned out light bulb. When he removed the cover, he noticed that the glass part of the bulb was missing. Its metal base, however, was still in the socket, so he grabbed a leatherman tool and started trying to remove the base. Unfortunately, he didn't think about securing power and tagging out the circuit. Because of this mistake, he spent the next 24 hours in a medical ward. Later, all hands attended a lecture on the hazards of working on live circuits.

In another case, a Marine was trying to switch off lights in a berthing area. The switch didn't work. Without permission, he went to the power panel and was removing a fuse when he was shocked by 110 VAC.

Finally, there's this story about a Marine corporal and a Navy AT2 who were working on an ultrasonic flaw detector. While they were replacing the unit's casing, the corporal repositioned an electrical wire that touched a cathode ray tube (CRT). Both *thought* the equipment was de-energized, but it wasn't. The corporal ended up with a shock, and everyone else got a briefing on procedures that call for verifying the discharge of a CRT or capacitor before starting to work.

Shipboard Marines don't have to learn their lessons about electrical safety the hard way. You can reduce the problem by following the example used aboard USS *Nassau* (LHA 4). Safety personnel there prepare for deployment by making sure Marines scheduled to sail with the ship understand shipboard electrical safety.

The training starts before Marines arrive. The pre-deployment package includes copies of "Regulations for Embarked Troops," which describes shipboard electrical-safety requirements. The Marines also receive pamphlets and flyers discussing specific regulations and outlining policies for electronic equipment.

When the Marines, their weapons, and supplies are loaded, personnel in the ship's SITE-TV station start airing closed-circuit TV programs about ship's routine, special services, and mishap prevention. "We encourage supervisors to let the Marines view these programs before setting up shop," noted a CPO in the safety department. "That way, they learn the hazards of using their electrical equipment aboard ship before electrician's mates inspect it." This system of orientation eliminates a need for safety observers while the Marines set up their spaces.

To speed up the equipment-check program, *Nassau* personnel post signs in common areas directing Marines to the testing sites (central locations). "As an extra precaution against electrical mishaps," the chief continued, "we visit the spaces while Marines set them up. This action promotes hospitality and helps ease bad feelings a newcomer may have about our shipboard rules."

Although troop berthing and weapons stowage are always primary considerations when Marines deploy aboard an LHA, they're not the only concern. It's also important that the Marines know the dangers of using untested or prohibited equipment. As the chief concluded, "Why should anyone have to be jolted by an untested electric razor before getting our message?"

*Some of the information for this article came from a 1991*Fathom*article by AEC(AW) Mark Childers, who then was the safety office CPO aboard USS*Nassau*. He now is assigned to VAW-120.*

*The author’s e-mail address is ktestorf@safecen.navy.mil.*

# Same Snake Bites Four

## By EMCS(SW) Michael Coleman, USN(Ret.)

“Chief, I just got shocked by this portable light,” said a lieutenant. “How about getting someone to check out the problem?”

“I’ll take care of it,” responded the EMC, who was standing nearby.

Assuming the light was the problem, the chief told an electrician’s-mate striker to replace it. The striker left and returned a few moments later with a new one, which the EMC plugged into the extension cord used with the first light. “Ouch!” he hollered, yanking his hand away from the plug. “This light is bad, too, or something else is wrong,” he grumbled. Like the lieutenant, though, he didn’t pursue the problem.

An ET1 came along a little later with a portable air sampler. “Ah! I’ll use this extension cord,” he said. Immediately, he also got zapped, but he just shook it off.

The stage now was set for yet another shock because the ET1 told an ET3 to get a new air sampler. When the ET3 entered the space, she accidentally brushed against a vidmar cabinet. Like her shipmates, she found out what it feels like to have electricity reach out and touch you. At this point, the work-center supervisors finally decided to find and fix the problem.

“Ridiculous!” you’re probably saying. “You made up that story. What ship ever has four people get shocked before someone takes the initiative to remedy the situation?” I assure you it really happened.

· Investigators found these problems:

· No one had safety-checked the extension cord before using it.

· The extension cord was missing its ground connection.

· The receptacle was loose, so it shorted out when anyone pushed on it.

Although this chain of events could have had tragic results, it ended harmlessly, which may satisfy some people. However, it doesn’t pay to accept such an all’s-well-that-ends-well attitude. Why? Because there are too many reports of similar mishaps. The victims come from all ratings.

The reason behind this problem is familiarity, which breeds a contemptuous attitude. Experienced technicians sometimes get careless. They take chances, use shortcuts, don’t follow tagout procedures, don’t wear rubber gloves, or work without supervision.

A key element in reducing or eliminating electrical shocks on your ship is making sure your supervisors accurately assess the risks involved. They also have to know how to manage those risks. In other words, they must think and plan ahead.

To ensure success, reacquaint everyone in electrical and electronic ratings with all the references1 that govern their work. These references make great required quarterly reading for your twidgits and snipes. Also, make sure everyone who does any kind of maintenance gets their required, annual, tagout training.

*At the time the author wrote this article, he was assigned to the Afloat Safety Programs Directorate at the Naval Safety Center.*

**For More Info...**

1 Everyone in electrical and electronic ratings should be familiar with these references: MIP 3000 A8-R; OpNavInst 5100.19C (with change 1), Chapters B11, C9 and D5; NSTM, Chapter 300, section 300-2.5; EIMB, Chapter 3; OpNavInst 3120.32C, Section 630.17.

**Let Me Count the Violations**

*By Lt. Tom Binner,*

*Naval Safety Center*

I cringe to think the only good news in a recent mishap report was that a Sailor who got shocked wasn’t killed.

The sequence of events started with a very short safety brief. Four Sailors (a chief, a PO2, a PO3, and an FN) then began removing a bad power supply from an energized switchboard. Their ship was in its homeport in a cold-iron status. After completing the energized-equipment checklist and reviewing technical info, the two senior people donned PPE and removed the power supply.

The PO3 then laid on the deck on his stomach to remove a bolt from inside the switchboard. Meanwhile, the FN grounded himself to the uninsulated, metal frame of the switchboard. The only PPE either wore were electrical gloves. They weren’t wearing faceshields, which would have made it hard for them to reach the work area. Their boots offered no protection since they were lying down.

The FN held the bolt from below while the PO3 used his gloveless right hand to turn the nut from above. When the PO3 lifted his head to get a better view of the bolt, he touched the 115-volt side of a step-up transformer. His body convulsed, causing him to strike the back of his head on other energized equipment above the transformer. Instinctively, his partner pulled him from the switchboard, placed him on the deck outside the safety lines of the work area, and checked for breathing and pulse.

The PO3 was dazed for about eight minutes and had a weak, rapid pulse, but he could breathe normally. He didn’t need any sutures for his cuts, but he spent the night in a hospital for observation.

I compared the narrative in the mishap report with the prescribed procedure1, then, finding several unanswered questions, I called the ship to clarify a few points:

***** An independent safety observer wasn’t on the scene. The senior person became a worker, which kept him from watching the big picture and protecting the people and equipment.

***** The ship was in a cold-iron status, so the workers didn’t have to do this job with the switchboard energized.

***** The safety brief inadequately described the energized circuits and their location.

***** The workers didn’t know all the requirements for working on energized equipment, including the rule for placing an insulating blanket over any nearby energized electrical equipment and exposed metal in the work area. They knew they needed the CO’s permission to work on energized equipment. However, he was off the ship for a conference, and the engineer officer was on leave, which left the engineering department without senior leadership. The main-propulsion assistant (MPA) was new aboard the ship and new to his position. The workers took the work authorization to the XO for signature.

Another problem was a lack of operational risk management. No one identified or assessed the hazards or considered the potential severity and probability of a mishap. When the XO, MPA and chief decided to work on energized equipment, their decision was based solely on convenience. The controls described in the previous paragraph clearly were necessary, but no one made sure they were in place. In the absence of the engineer officer, neither the MPA nor the electrical officer supervised the operation.

This mishap is another example of the problems that plague the fleet: lack of training and smug attitudes.

*The author’s e-mail address is tbinner@safecen.navy.mil.*

**For More Info...**

1 Paragraph 300-2.5.2 of NSTM 300 (Electrical Plant-General) describes how to work on energized equipment.

**Editorial:**

**Is Breaking the Rules Worth the Gamble?**

*By EMC(SW) Carl Henry,*

*USS*Nicholson*(DD 982)*

Until I came to the Naval Safety Center in April 1998, I thought I was the only fleet electrician’s mate who ever cut corners to get a job done. I had no idea so many others were making the same mistake. Now I understand why electrician’s mates are always under the microscope during major inspections and assist visits.

Here’s an example of a shortcut-gone-wrong that I found while researching this editorial:

A PO3 was helping his chief petty officer and work-center supervisor troubleshoot the ventilation system in a main space.  The PO3 was looking over the shoulders of these two senior technicians, watching their every move.

When the chief and the supervisor left to investigate the vent motor, the PO3 decided to check the controller some more.  He found a wire had been damaged by heat. As he reached in and touched the wire, he made an important discovery: The controller still was energized.

Too often, our quest to take care of all the problems that arise during a hectic day turns into a painful demonstration of what happens when you take shortcuts. We continuously and consciously toss rules aside, and soon this bad habit becomes an accepted way of life.  

I was staggered to learn that electrical mishaps aboard surface ships and submarines numbered 1,095 for FY96 through FY98. In other words, ships reported a mishap a day for three consecutive years. Here are some of the major causes I found during my research:

**A lack of QA by repair personnel.** Senior leaders from the electrical and electronic ratings didn’t make sure repairs were made as required.

**A lack of supervision.** These problems stemmed from insufficient planning to ensure the right person was assigned to do the job. In troubleshooting, repairs and PMS, supervising junior personnel is crucial.

**A lack of training.** How can we expect a fireman or new third class straight from “A” school to know everything about shipboard equipment? Supervisors know it takes deckplate training to prepare junior Sailors to do maintenance and repairs adequately. Nevertheless, we routinely think, “They will figure it out,” and send them off.

In some cases, overwhelming workloads interfere with training schedules. Leaders have so many high-priority items on their work lists that little time is left for training. The danger in this situation is that Sailors who mistakenly think they understand a system may decide to “wing it.” This choice may be especially tempting if they happen to be working in an isolated area with no one around to monitor their actions.

**Broken or damaged equipment**.  This problem can start with something as simple as a technician not repairing a piece of equipment correctly. Before long, you probably will have other equipment problems (e.g., chafed cables inside controllers, caused by improper routing of cables; or missing hardware). 

**Failure to tag out equipment.** We know better than to let people hang red tags inside fuse boxes, so why let them just tag out the 115-VAC, 400-Hz circuit on a piece of gear with multiple power supplies? How are we going to feel if they get zapped because they are too busy to read the warning placard about multiple power sources?

As supervisors, we need to insist that workers do tagouts for all necessary work. Even if they have to leave another job to go do a tagout that may delay their liberty--don’t let them off the hook. The alternative is a “touching” experience like the one the PO3 in the earlier example had. Many ships already are short-handed. We can’t afford to lose more Sailors.

How do we solve the tagout problem? I feel we need a tougher system of accountability, starting with supervisors. Hold them accountable for giving workers the training, test equipment, PPE, and time to do their jobs correctly. If these efforts fail, we need to try EMI and comments in fitness reports and evaluations. As a last resort, I recommend that we take them to Captain’s Mast. That’s already happening aboard a *Ticonderoga*-class cruiser I visited recently.  

From a program point of view, if Sailors get shocked or electrocuted because of improper tagouts, then the QA and training programs also have failed. This cascading effect can doom a ship trying to pass an exam, which, unfortunately, is usually the only time anyone ever considers the total package. The thinking should be that a ship is always in an exam.

Generally speaking, if a ship isn’t in some kind of training mode and no one is watching, the violations will occur. Why? Because the prevailing attitudes usually are, “Who cares?”

Use this electrical-safety issue of *Fathom* to**supplement the official guidance.1 When you short-cut these rules and established procedures, you increase the risks. Even if nothing happens, you’re gambling--and stacking the odds against yourself.

*The author was assigned to the Afloat Safety Programs Directorate at the Naval Safety Center when he wrote this article*.

**For More Info...**

1 The “official guidance” includes the NSTM, Chapter 300; the NavOSH Program Manual for Forces Afloat (OpNavInst 5100.19C), with change 1; OpNavInst 3120.32C.