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Arc Flash Gladstone MCC - Coggle Diagram
Arc Flash Gladstone MCC
Human Error Interaction
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Less than adequate attention by trades-person electrician to ensure the third year apprentice electrician has tested for dead on circuit breaker when isolation point one (1) was isolated for main board
Failed to recognise isolation requirements prior to work on electrical equipment (e.g., test for dead)
Management
Contractors identified circuit breaker replacement due to greater capacity requirements (AMMANN & A.C.E.S.)
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Supervision
Failed to check electrical equipment (test for dead) prior to completing replacements of circuit breaker
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Maintenance
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Electrical system to the Gladstone Asphalt Plant upgraded/ retro-fitted for the new digital display (voltmeter) and new interface (temperature and tracking for Brisbane Lab team)
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Inspection
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Inspection of MCC post incidents identified the electrical power supply for circuit breaker was located outside MCC main building
Systems
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Main board and circuit breaker isolation point should be isolated from isolation point to outside of MCC
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Environmental Factors
Assumption made that as main board was isolated and so was the circuit breaker 
Fault finding relies on experience and system failure to identify fault. E.g., circuit breaker was running from a separate isolation point.
Red traffolyte labels missing to show correct isolation points
Method/ Process
Less than adequate SWMS review of critical steps at beginning of task/ job. For example, debrief concerning isolation points and job steps
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