In 2014, a BC Hydro electrician made inadvertent hand contact with a 12-kV bus while working on a station disconnect switch installation. The electrician lived but ended up losing both arms below the elbows. This article provides an overview of the incident, the two-and-a-half-month investigation, and the corrective action of implementing improved hazard identification and effective barriers as a part of job planning. It briefly introduces the Tripod Beta methodology of incident analysis, which focuses on barriers that could have been implemented to prevent or mitigate the outcome. The article will also reveal how human factors contributed to the incident as well as how a very detailed and thorough tailboard discussion focused on generic hazard categories rather than specific hazard sources. The corrective-action implementation included introducing a barrier-effectiveness tool called the hazard barrier reference (HBR) that crews now use as a part of their tailboard process. If crews cannot implement at least one effective barrier from the HBR sheet, that triggers a hazard barrier deficiency process that logs the work situation in a registry. The Hazard Barrier Governance Committee was formed to address these deficiencies and look for barrier improvements.

中文翻译：

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实施危害识别和障碍实施的改进，作为严重电接触事件的纠正措施

2014 年，BC Hydro 的一名电工在安装电站隔离开关时无意中用手接触了 12 kV 母线。电工活了下来，但最终失去了肘部以下的双臂。本文概述了该事件、为期两个半月的调查，以及作为工作计划的一部分实施改进的危险识别和有效障碍的纠正措施。它简要介绍了事件分析的 Tripod Beta 方法，该方法侧重于可以实施以防止或减轻结果的障碍。文章还将揭示人为因素如何导致事件，以及非常详细和彻底的尾板讨论如何侧重于一般危险类别而不是特定危险源。纠正措施的实施包括引入一种称为危险屏障参考 (HBR) 的屏障有效性工具，机组人员现在将其用作尾板过程的一部分。如果工作人员无法实施 HBR 表中的至少一个有效屏障，则会触发危险屏障缺陷流程，将工作情况记录在注册表中。危险屏障治理委员会的成立是为了解决这些缺陷并寻求屏障改进。