OPERATING EXPERIENCE FLASH
AMEA-FGBU-OEF-2024-002 HIPO Near Miss Electric Shock due to MCC breaker defect.
T&S GBU-OEF-001– Fatal Accident by Electrocution during cable
What Happened
reconnection work
On 29th February 2024 at 14:39hrs, a HiPo near
miss incident occurred at Shedgum Plant of
Tihama Power in Saudi Arabia where an BUSSBAR
electrical technician, while wearing protective
gloves, felt a tingling sensation when he came
into in contact with an exposed cable (480VAC)
of a motor terminal. The technician did not
sustain any harm or injury at the time of exposure.
Work was immediately stopped and the situation
subesquently reported to the Safety Controller.
On the day of the event, there were two permits
issued in parallel for different activities - (1)
inspection of MCC1-AC motor starter modules and associate panels and (2) a preventive maintenance of
88PF-1 motor. The first permit was isolated with MCC 1-AC incomercommon (bussbar) electrical system
(rack out, locked and tagged) while the second permit with MCC 1-AC 480VAC breaker for PF fan1 motor
(open, locked and tagged). The absence of live energy check was carried out (after the bussbar had been
isolated) on breaker contactor output with zero voltage reading before starting the work.
At 13:55 hours, Acceptor cleared the permit for MCC 1-AC after completing the work. The Safety Controller
cancelled the permit (1) and Designated Person de-isolated the system and energized the bussbar at 14:15
hours. It was at 14:39 hours that the electrical technician working on PF fan1 motor reported the electic shock
incident. Another acceptor checked for abscene of energy and measured a reading of 491VAC at the
terminals. On further investigation, it was physically re-confirmed that the point of isolation (480VAC breaker)
for the motor was isolated (rack out, locked and tagged) as per the breaker handle position.
What Went Wrong?
• Following the incident, the breaker cubicle was physically inspected and it was observed that the
MCCB breaker mechanism had not fully opened although the switching handle indicated an open
condition from the outside. The breaker contactor was also observed engaged. Attempts were made
to open the breaker, fuses were removed, door mechanism was checked, and the spring was refixed.
• A simulation was done on PF motor #1 breaker & other similar breakers, and it was confirmed that
the MCCB breaker internal mechanism was defective and malfunctioned at some point, preventing
a correct isolation of the individual circuit.
• The breaker ON/OFF indicator lamps were defective, preventing a correct status of the breaker.
• The absence of energy check for the breaker had been conducted on issue of the permit, after the
busbar had already been fully isolated (no energy). This situation prevented the VAT test to correctly
indicate the actual status of the MCCB as the point of isolation for the PF fan motor. A continuity
test at this stage could have indicated a problem with the MCCB breaker.
Contact: AMEA HSE DEPARTMENT
OPERATING EXPERIENCE FLASH
AMEA-FGBU-OEF-2024-002 HIPO Near Miss Electric Shock due to MCC breaker defect.
T&S GBU-OEF-001– Fatal Accident by Electrocution during cable
Learning / Recommendations reconnection work
1. Electrical points of LV isolations can fail at any time. This hazard shall be included in the Task
Based Risk Assessment & POWRA/LMRA. (e.g. breakers with no physical separation)
2. Both Operations & Maintenance teams shall assess the best mitigation measures (e.g. LV isolation
plan, cascading of permits, appropriate method for testing absence of energy or conductivity, selection
of electrical PPE, personal warning devices,…)
3. Ensure preventive maintenance for LV breakers as per OEM recommendations / industry best practice.
4. Perform routine inspections of indication lamps, measuring instrumentation & functionality of apparatus.
Contact: AMEA HSE DEPARTMENT
