Post-Outage Handoff: Keep Good Work From Getting Lost

A Friday test that did not finish

The breaker commissioning tests were supposed to wrap up on a Friday, and they did not. In a case study that NERC published on December 30, 2024 as Lesson Learned LL20241201, the protection isolation switches at one substation were left open over the weekend, and a relay technician who had made a field change without properly communicating it went home.

Operations never learned the as-left status. When a phase-B-to-ground fault hit a 230 kV line, the relaying at one end was disabled, so all four 230 kV lines into the station tripped open at their remote ends. NERC does not name the utility. One of the entity's corrective actions was to improve communication between operations and field personnel on the status of protection equipment before a crew leaves a substation.

The write-up does not fault the relay work itself.

Its observations are about who knew how the equipment was left, and who did not. Regulators have tried to measure how often commissioning misses and human error, including as-left mistakes like this one, trip something. A joint review by FERC, NERC and the regional entities, dated November 2, 2021, started from a sample of NERC's MIDAS misoperation data that put the share of misoperations traceable to issues commissioning should have caught at between 18 percent and 36 percent. ReliabilityFirst tracks "As-Left Personnel Error" as its own cause, and in its September 2025 assessment 39% of misoperations in its footprint from 2020 to 2024 traced to human performance.

Handover loses what the crew knew

Paul Sheridan, EMEA lead for digital capital projects and delivery transformation at Accenture Data Center Services, says in a September 16, 2026 opinion piece for DCD that the specialists who configured the systems and witnessed the testing "move to the next project," and operators are left to reconstruct what the delivery team already knew. "That is the real handover failure," Sheridan says. "Not missing documents. Missing memory."

A NIST-commissioned study of 2002 costs put the labor that owners and operators spent checking that facility information matched what was actually set in place at $4.8 billion. That was the single largest piece of the $15.8 billion the study tied to poor interoperability. The figures are more than 20 years old.

Build the record around each system and how it was left

An outage-wide closeout binder is too broad for the supervisor standing in front of one relay panel. Build a turnover package for the smallest piece the plant can accept and own, perhaps one breaker position or one motor control center, so Area A can go back to operations while Area B stays under outage control.

The most useful page in that package is the list of everything not in its normal state. Recommendation 10 of the FERC-NERC review already sets out a minimum isolation log, which covers the repositioning of test switches, temporary jumpers and shorting blocks, who made each change, the time and date of the change, and when the equipment was returned to normal. Use it as the template for the exceptions register. Extend it to bypasses, inhibited alarms, temporary repairs and deferred tests.

Test records need the same discipline. NETA's guide to test reports under ANSI/NETA MTS and ATS calls for both "as-found" and "as-left" results on the test data record. A row that just says "tested" does not meet that, so write down the test, the date, the result and who accepted it.

Keep incomplete work and operating exceptions apart. An exception is a known departure from the final condition that the site authority has agreed to run with under a stated limit, with a work order and an end date attached, and if nobody with that authority signed for it, it is still incomplete work.

The 2023 NEC added commissioning to 700.3, 701.3, 706.7 and 708.8, rules that until then had required only a witness test. Michael Johnston, NECA's retired executive director of codes and standards, says in Electrical Contractor that the commissioning process "does not reduce the contractor's responsibility" to deliver a complete, finished and fully functioning installation.

Walk it down before anyone signs

Signatures collected in a conference room before the receiving crew has seen the equipment prove very little. A better order starts with a completeness review by the performing lead, moves to a joint walk-down and a check of the evidence, and leaves the acceptance decision for last. The FERC-NERC review recommends a final walk-down on a checklist that confirms test switches and controls are in the correct state, CT circuits are un-shorted, alarms are restored to service and SCADA and RTUs are working.

Anything the performing lead and the receiving operator disagree about becomes an open item with a name on it.

Under 29 CFR 1910.333(b)(2)(v)(A), before circuits or equipment are reenergized, even temporarily, a qualified person has to conduct tests and visual inspections, as necessary, to verify that tools, electrical jumpers, shorts and grounds have been removed. The thing left behind tends to be small. Russell R. Safreed, general manager at CBS ArcSafe's West Virginia location, and Charles Mark McClung, who founded MarTek Limited, describe in Plant Services a facility owned by a Fortune 500 company where "a blown current-limiter sensing wire was left disconnected on one end." When the breaker was returned to service, the loose lead touched grounded metal and an arc blast followed.

"Accepted with comments" is too vague to run a plant on. The receiving authority has three honest answers (accepted, accepted with listed exceptions, or not accepted), and the first operating shift should then confirm that every exception shows up in the tools that shift actually uses.

An open item without an owner stays open

In July 2018, oil samples at National Grid's North Hyde substation in London showed a category 1 moisture reading on a bushing of transformer SGT3. National Grid's guidance said that level indicates "an imminent fault and that the bushing should be replaced." The reading went into the online system. According to NESO's final review of June 30, 2025, "the mitigations appropriate to its severity were not actioned," and planned outages to maintain SGT3 in 2021, 2022 and 2024 never went ahead. On March 20, 2025, a bushing on SGT3 failed and started a fire that cut power to 66,919 SSEN customers.

Heathrow decided to close at 01:11 the next morning.

The HSE report on Buncefield, a UK oil depot, found that the level gauge on tank 912 stuck 14 times between its return from maintenance on August 31, 2005 and December 11. Supervisors logged it as a fault only some of the time. The high-level switch needed a padlock to keep its check lever in the working position, and while the switch was tested periodically, "none of the staff" at the site knew the padlock had to be replaced afterward.

So every entry in the exceptions register gets an owner, a work order and a next review date. A rejected package names the failed check and the fix, and nothing else.

Keep the people until the record clears

29 CFR 1910.147(f)(4) requires specific procedures at shift or personnel changes "to ensure the continuity of lockout or tagout protection." Those procedures have to provide for the orderly transfer of lockout or tagout device protection between off-going and oncoming employees. OSHA's coordination guidance for host employers, contractors and staffing agencies says information is communicated "before on-site work starts and, as needed, if conditions change."

The UK Health and Safety Executive says the majority of accidents caused by failed shift-handover communication involved planned maintenance work, and its guidance asks for handovers that are face to face, two-way and given as much time as they need. At Buncefield, supervisors tried to allow 15 minutes. They knew they were not being paid for it.

The people who can answer as-left questions are the people the next job wants. In the AGC and NCCER 2026 workforce survey, which drew 1,830 respondents, 87 percent reported openings for hourly craft positions. Put closeout hours by role into the crew plan, keep the performing lead and the relay tech who made the field changes on site until their packages clear, and build the staffing contingency before the outage starts.

Jason Sneed, a project manager at Hoar Construction, describes moving AdventHealth Zephyrhills, a working hospital in Florida, from its old generator plant to a new one. Most of the work ran after 5 p.m. and usually stopped by midnight. His team met all involved trade partners the day before each electric panel was worked on. "A plan is only effective if it's fully understood by everyone who plays a part in it," Sneed says. Installing the two 500-ton chiller plants took one day and two full months of planning.

Forrest Farson, an AEP project manager, ran the rebuild of the Mulberry Creek substation on the ERCOT system, which carries multiple 345-kV and 138-kV lines, and several planned outages there were canceled. Asked by T&D World for advice, Farson says to "understand your constraints early" and to "invest in capturing institutional knowledge."

Sources

1. Lesson Learned LL20241201, Root-Cause Analysis Tools: Events and Causal Factors Charting, North American Electric Reliability Corporation, December 30, 2024.
2. FERC-NERC-Regional Entity Joint Review of Protection System Commissioning Programs, Federal Energy Regulatory Commission, November 2, 2021.
3. 2025 Misoperation Assessment, ReliabilityFirst, September 2025.
4. Data centers are losing the intelligence they already paid for, Paul Sheridan, DCD, September 16, 2026.
5. NIST GCR 04-867, Cost Analysis of Inadequate Interoperability in the U.S. Capital Facilities Industry, National Institute of Standards and Technology, August 2004.
6. Guide for Complying with the Requirements of NETA MTS and ATS Field Testing Standards, Section 5.4 Test Report, InterNational Electrical Testing Association, September 2021.
7. Commissioning and Witness Testing: The new rules add additional steps and processes, Michael Johnston, Electrical Contractor, June 15, 2023.
8. 29 CFR 1910.333, Selection and Use of Work Practices, Occupational Safety and Health Administration, accessed September 29, 2026.
9. 29 CFR 1910.147, The Control of Hazardous Energy (Lockout/Tagout), Occupational Safety and Health Administration, accessed September 29, 2026.
10. Why a return-to-service plan is key to reducing electrical safety risks following maintenance outages, Russell R. Safreed and Charles Mark McClung, Plant Services, September 26, 2023.
11. North Hyde Review Final Report, National Energy System Operator, June 30, 2025.
12. Buncefield: Why did it happen?, Health and Safety Executive for the COMAH Competent Authority, February 2011.
13. Communication and Coordination for Host Employers, Contractors, and Staffing Agencies, Occupational Safety and Health Administration, accessed September 29, 2026.
14. Human factors: Shift handover, Health and Safety Executive, October 29, 2024.
15. Construction Workforce Shortages Remain Acute Despite 'Soft' Market Conditions As Data Centers Strain Labor Supply, Survey Finds, Associated General Contractors of America, September 3, 2026.
16. Coordinating Power Shutdowns in an Active Hospital, Jason Sneed, Hoar Construction, June 12, 2024.
17. Q&A: Rebuilding a Critical Substation While Supporting New Data Center Growth, Nikki Chandler, T&D World, August 10, 2026.

Featured image: Carol M. Highsmith, Library of Congress (public domain).