On May 3, 2015, a serious electrical incident occurred at one of the Department of Energy's national laboratories. Preventative maintenance was being performed on 13.8-kV switchgear, which included the task of cleaning individual switchgear cubicles. A wireman unknowingly entered an energized cubicle in order to clean it with a commercial spray cleaner. When he proceeded to spray the cleaner onto the energized components, he suffered severe injuries from the resulting arc flash and blast. This article will breakdown the discussions, thought processes, and planning decisions that were made from both the facility and worker's perspective. It will describe risk factors that increased the likelihood of this incident and breakdown how the addition of a single risk control measure could have prevented this incident. Finally, it will describe the details leading up to the incident, the incident itself, the response, and lessons learned. The lessons learned associated with this incident emphasizes the importance of using tools to promote active thinking during both the planning and execution of the work in order to reduce the likelihood of human errors associated with complacency.

中文翻译：

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自满是你的敌人：弧闪事件剖析和经验教训

2015 年 5 月 3 日，美国能源部的一个国家实验室发生了严重的电气事故。正在对 13.8 kV 开关设备进行预防性维护，其中包括清洁单个开关设备柜的任务。一名接线工在不知情的情况下进入了一个通电的隔间，以便用商用喷雾清洁剂对其进行清洁。当他继续将清洁剂喷到通电部件上时，他因产生的电弧闪光和爆炸而受了重伤。本文将从设施和工人的角度分解讨论、思考过程和规划决策。它将描述增加此事件可能性的风险因素，并分解添加单一风险控制措施如何防止此事件发生。最后，它将描述导致事件的细节、事件本身、响应和经验教训。与此事件相关的经验教训强调了在工作计划和执行期间使用工具促进积极思考的重要性，以减少与自满相关的人为错误的可能性。