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Incident Damage to Gen 3 HV Cable During Cable Ladder Lid Installation …
Incident
Damage to Gen 3 HV Cable
During Cable Ladder
Lid Installation
21/07/26
Assumptions
maintained
unchallenged
Inadequate consultation
&Shared Understanding
People & Team Factors
(People working within the system as i)
Technical System & infrastructure design
(Latent conditions in the physical system increased vulnerability)
Cable status not visually identifiable
No physical seperation between systems
Energised and non-energised assets co-exist
Cables partially concealed before drilling
Shared cable ladder (Gen 3 Gen 4 HV cables)
No drill stop or physical barrier
No alternative fastening equipment available
Drilling and riveting used - introduduced intrusion hazard
Work Management System
(Determines how work is planned owned & controlled)
Task not recognised as electrical interface activity
Electrical consultation not triggered
Mechanical scope owned the work activity
Electricity CCV not triggered
Work managed by trade ownership
Permit pathway unclear/not applicable
Hazard ownership unclear
Change in system State
(Not reassessed or incorporated in subsequent work planning & risk assessments)
Commissioning & Change Management
(Changed the System State but planning did not adapt)
No re-assessment of outstanding works
Category C Punch-list process
Changed Risk profile new operational HV Infrastructure
Mixed construction and operational environment created
Gen 4 Commissioned
(Pre-RNR) - (NOE Issued)
Change not intergrated into planning and risk assessments
Risk Management System
(Relied on Admin processes rather than understanding of major hazard exposure)
Hazard Identification missed (Interface risks overlooked)
Control selection inadequate (Inappropriate work method selected)
Task Definition Incomplete (Who, What, Where, How
CCV not complete, JHA inadequate, Elect JHA not reviewed
Organisational Systems & Governance
(What the organisation had in place)
Verification & Assurance
(Defences and assurance barriers were not triggered/ineffective)
JHA Moc review inadequate
No CCV undertaken
No Isolation verification/review for adjacent HV Cable
No Isolation feasibility review
No electrical consultation
No SWMS developed/reviewed
Take 5 Inadequate