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Arc Flash Gladstone MCC - Coggle Diagram
Arc Flash Gladstone MCC
Environmental Factors
Assumption made that as main board was isolated and so was the circuit breaker
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Red traffolyte label missing to show correct isolation points
Fault finding relies on experience and system failure to identify .E.g., circuit breaker was running from a separate isolation point
Human Error Interaction
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Less than adequate attention by trade-person electrician to ensure the third year electrician has tested for dead on circuit breaker when isolation point 1 was isolated for main board.
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Inspection
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Inspection of MCC post incidents identified the electrical power supply for circuit breaker was isolated outside MCC main building.
Management
Contractors identified circuit breaker replacement to greater capacity requirements (AMMANN & A.C.E.S)
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Systems
Schematic developed and was current but not reviewed at time of job task 2024
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Main board and circuit breaker isolation point should be isolated from isolation point outside of MCC
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Maintenance
Electrical Schematic developed for commissioning 2011
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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Method / Process
Less than adequate pre -task briefing concerning the task with key stake holders (AMMANN & A.C.E.S )
Less than adequate SWMS review of critical steps at beginning of task/job. For example , debriefing concerning isolation points and job steps
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Supervision
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Failed to check electrical equipment (test for dead) prior to completing replacements of circuit breaker.
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