Massachusetts FACE MA-93-09

Self-Employed Massachusetts Electrician Dies During Electrical Connection of Equipment

SUMMARY

On Monday, June 21, 1993 a 32 year old, male, self-employed electrician was electrocuted while connecting a hydraulic press brake at a Massachusetts manufacturer of steel toxic waste containers. Apparently believing that the circuit was de-energized, as he had left it before his break, the victim cut through the taped end of a cable with insulated wire shears. The victim became energized and yelled to his father who was working with him to shut off the breaker. The victim's father turned the breaker off, and the victim collapsed to the floor. Emergency medical services responded within minutes and transported the victim to a regional hospital, where he was officially pronounced dead less than one hour later. To prevent similar future occurrences, the Massachusetts FACE Project recommends that electrical contractors:

ensure that lockout and tagout procedures are followed when servicing machines and equipment or working on electrical circuitry

develop written safety rules and procedures to protect their employees and themselves on the job, including but not limited to lockout tagout procedures.
In addition, employers should:

ensure that lockout tagout procedures are followed by electrical contractors performing repair or maintenance work on their premises.
 

INTRODUCTION

On June 21, 1993, a medical examiner telephoned the Massachusetts FACE Project's hotline to report the electrocution of a 32 year old, self-employed electrician earlier in the day. An investigation was initiated.

On July 20, 1993, the MA FACE Field Investigator travelled to the victim's home and conducted an in-depth interview with the victim's mother and father. The victim's father, who routinely assisted his son on various jobs, was with him at the time of the incident and witnessed his death.

The death certificate, municipal department of public safety incident summary, Massachusetts Department of Labor and Industries incident summary, personnel statements, the victim's biographical profile and assorted news clippings were obtained during the course of the investigation.

The victim was a self-employed, licensed, journeyman electrician in business for 2 years and 6 months at the time of his death. In order to obtain his license the victim had completed classroom training and a 4,000 hour on-the-job apprenticeship. He had also passed the state-mandated licensing examination.

The victim did not employ personnel, although his father routinely assisted him. He did not have written safety or lockout tagout procedures in place at the time of his death.

INVESTIGATION

A Massachusetts manufacturer of steel toxic waste containers contracted a self-employed electrician to connect new equipment and install new lights in its plant. The self-employed electrician and his father began the work in the plant on June 18, 1993. The electrical system in the plant was a 200 amp, three phase main disconnect fed by a 480 volt, three phase, three wire ungrounded Delta system. This disconnect fed a three phase distribution panel which fed a bus duct that powered the plant machinery, two dry-type step down transformers, a welding machine, and temporary wiring which the victim used the day of the incident.

Prior to leaving the plant on Friday, June 18, the victim and his father disconnected a temporary lead on a hydraulic press brake and made a permanent connection to the brake with another cable. They then taped and rolled up the end of the temporary lead and left it in the building rafters for use on Monday, June 21.

On Monday morning, June 21, the plant president and an assistant routinely re-energized the building circuitry. Plant policy called for deactivating most building circuitry off-shift (nights, weekends and holidays). Arriving at the plant at approximately 9:30 a.m., the victim and his father resumed the work they had left on Friday, June 18th. Making sure to deactivate the circuit breaker which powered all the electrical lines they were to work on, the victim and his father spent approximately two hours wiring light switches and a leaf break lockout. The two then took a half hour break.

Returning from their break around noon, the father-son team began preparing the previously taped and coiled temporary lead for connection to a new hydraulic press for a test run. The victim's father recalled asking his son if he thought the breaker was still deactivated. His son reassured him that it was, and began to cut into the taped end of the lead with his insulated wire cutting shears. Shortly afterwards, the victim became energized and yelled to his father to turn off the breaker which was only twenty feet away. When this was done, the victim collapsed to the floor. Apparently, someone had turned the circuit back on to use the welding machine while the two were on break.

Hearing the father's plea for help, two plant workers responded from their lunchroom to see what had happened. Finding the victim lying on the floor, open-armed and on his back, one of the workers detected no pulse and called 911 for emergency response. When no one answered, he directly called some emergency responders who arrived on-site in minutes. The victim was transported to the local hospital, where he was officially pronounced dead approximately forty-five minutes following the incident.

CAUSE OF DEATH

The Medical Examiner listed the cause of death as electrocution.

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Electricians should always follow lockout and tagout procedures when servicing machines and equipment or working on electrical circuitry.

Discussion: Although the victim de-energized the circuit breaker in the morning, he did not place a lock on it, nor a tag indicating that the circuit was shut off for servicing. Furthermore, the victim did not test to verify that the system was de-energized. As a result, a plant employee turned the circuit back on while the victim was on his break, and the victim was later electrocuted. If lockout and tagout procedures had been followed, as specified in U.S. Department of Labor 29 CFR 1910.147, this incident could have been prevented.

Recommendation #2: Self-employed electricians should develop written safety rules and procedures to protect their employees and themselves on the job, including but not limited to lockout tagout procedures.

Discussion: Although OSHA does not require the self-employed to develop their own safety programs, individual contractors should generate safety rules and procedures which are based on the relevant OSHA standards. Furthermore, contractors should conduct routine jobsite hazard surveys, and develop safety plans, for each job that they do. In this case, lockout tagout procedures were important safety issues to be considered for the electrical service work at the plant.

Recommendation #3: Employers should ensure that lockout tagout procedures are followed by electrical contractors performing repair or maintenance work on their premises.

Discussion: U.S. Department of Labor 29 CFR 1910.147 requires employers to develop a program for controlling unexpected energy release during servicing or maintenance of equipment and machines. The standard defines the practices and procedures that are necessary to shut down and lockout or tagout machinery. Subsection (f)(2) of the Lockout Tagout Standard specifies that the on-site employer and the outside employer, or contracting electrician, shall inform each other of their respective lockout or tagout procedures and that the on-site employer shall ensure that his/her employees comply with the contractor's procedures. While electrical contractors should develop their own lockout tagout procedures, these procedures cannot be followed without the on-site employer's cooperation. Had the employer sought to coordinate the victim's lockout tagout plans with the company's own procedures, this incident may have been prevented.

REFERENCES

1. Office of the Federal Register: Code of Federal Regulations, Labor 29, July 1, 1990: Parts: 1910.147

To contact Massachusetts State FACE program personnel regarding State-based FACE reports, please use information listed on the Contact Sheet on the NIOSH FACE web site Please contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.

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