Fatality Assessment and Control Evaluation (FACE) Program

Electrician's Helper Electrocuted After Contacting 480 Volt Bus Wires for an Overhead Crane

Summary

On June 17, 1991, a 21-year-old electrician's helper was electrocuted after contacting the exposed 480 volt bus wires that supply power to a movable overhead crane. The incident occurred while the worker was running cables for surveillance cameras at a factory which produces foundry equipment. While a co-worker was passing the coaxial cables over an I-beam supporting the bus wires, the victim contacted the energized wires and was electrocuted, NJDOH FACE investigators concluded that, in order to prevent similar incidents in the future, the following safety guidelines should be followed:

• Employers must insure that employees de-energize electrical systems prior to any work being performed near them. Employers should also insure that employees implement lockout/tagout procedures and test the system to verify that it has been de-energized before beginning work.
  
  
• Employers should provide and enforce the use of personal protective equipment to protect employees from electrical hazards. Guarding and shielding should also be used to prevent contact with energized conductors.
  
  
• Employers should develop, implement, and enforce a comprehensive safety program which includes worker training in avoiding electrical and other safety hazards.
  
  
• Employers of electrical workers should insure that all workers are trained in basic cardio-pulmonary resuscitation (CPR).

Introduction

On June 18, 1991, NJDOH FACE personnel were notified by the area OSHA office of a work-related electrocution that occurred the previous day. On the same day, a FACE investigator visited the site with an OSHA compliance officer to interview the factory manager and photograph the scene. Other information was derived from the employer and co-worker, the OSHA compliance officer, police report, and medical examiner's report.

The employer is a small electrical contractor who has been in business since 1970. The company employed 4 people at the time of the incident, including the owner, two electrical helpers, and an office worker. The victim was a 21-year-old male who had been employed by the company for eight months. He had completed his apprenticeship and had previous experience as an electrician's helper.

Investigation

The incident occurred inside a large factory that manufactures heavy equipment for foundries. The factory had hired the electrical contractor to install video surveillance cameras in different areas of the plant. On the day of the incident, the first day of the contracted work at the factory, the owner of the contracting company walked with his two helpers (the victim and his co-worker) through the plant to explain the job. The owner states that he does this at each job in order to point out the locations of important equipment (such as breaker boxes) and to identify any safety hazards. During the walk he showed his helpers the bus wires for the overhead cranes, explaining that the wire voltage was 480 volts and that they should be careful with them. After walking through the job, he left them to do the work.

The job required the victim and his co-worker to wire coaxial cable (the cable that carries the video signal) over and around the ceiling supports of the factory. To reach the ceiling, the factory provided a "scissor lift", an electrically driven lift that vertically raises a large platform equipped with a safety railing. The workers would raise the platform, pull the cables over the supports, and move the lift forward as needed. The job also required wiring the cables over three overhead cranes. These cranes are designed to move approximately 15 feet overhead along rails, drawing power from the exposed three-phase 480 volt bus wire system. As the crane moves forward, brushes on the crane make contact with the exposed wires, supplying power to the crane. The bus wires are mounted to the side of a large steel I-beam that also serves to support the crane.

Throughout the day, the two electrical helpers labored to wire over the supports and overhead cranes. When they reached the first two cranes, they ran the cables over the energized bus bars without incident. At about 4:30 p.m., they reached the third crane and positioned the scissor lift directly under the I-beam supporting the bus wires. After raising the lift up to the I- beam, the helpers stood at opposite ends of the lift platform to wire over the beam. As they ran the cables, the victim warned his co-worker about the 480 volts they were working near. Due to the differing heights of the roof on each side of the beam, the two were unable to see each other as they worked (see diagram). The co-worker stated that he was attempting to pass the cables over the I-beam to the victim when he heard a bang (the bang was apparently caused by the victim contacting the bus wires). The co-worker then called to the victim two or three times before he saw him fall flat on his back onto the lift platform. At this point the lift was lowered and the emergency medical service (EMS) was notified. The police arrived a few minutes later and attended to the victim with the assistance of factory first-aid personnel. The victim, who was breathing and had a weak pulse, went into cardiac arrest at the scene, The police immediately began CPR on the victim until the EMS arrived. The EMS continued CPR and transported the victim to the local hospital emergency room where he was declared dead. Due to the differing heights of the roof, it appears that the victim apparently climbed onto the safety railing of the platform in order to reach over the I-beam. Burn marks on his chest and elbow indicate that he may have leaned or fell onto the bus wires while reaching for the coaxial cables.

Cause of Death

The cause of death was attributed to electrocution. The medical examiner's report stated that there were electrical burns on the chest and right elbow of the victim's body.

Recommendations/Discussion

Recommendation #1: Employers must insure that employees de-energize electrical systems prior to any work being performed near them. Employers should also insure that employees implement lockout/tagout procedures and test the system to verify that it has been de-energized before beginning work.

Discussion: In this incident, the helper was electrocuted after taking the unnecessary risk of working near energized wires. This is a violation of the federal OSHA standard 29 CFR 1926.416(a)(l) which prohibits employees from working in the proximity of energized power circuits unless the circuit is de- energized or guarded. It is imperative that employers identify all potential electrical hazards and, if possible, de-energize circuits before working on or near them. After de-energizing, a lockout/tagout procedure should be used by the workers to insure that electrical systems are not inadvertently re-energized while working on it. Finally, all circuits should be tested to verify that they are de-energized.

Recommendation #2: Employers should provide and enforce the use of personal protective equipment to protect employees from electrical hazards. Guarding and shielding should also be used to prevent contact with energized conductors.

Discussion: In this case, the helpers were not issued or used any type of electrical personal protective equipment (PPE). In situations where workers may potentially come in contact with energized conductors, the employer should require the use of PPE such as insulating gloves, aprons, and sleeves. Guarding and shielding equipment (such as insulating blankets and line hoses) may also prevent inadvertent contact with energized circuits.

Recommendation #3: Employers should develop, implement, and enforce a comprehensive safety program which includes worker training in avoiding electrical and other safety hazards.

Discussion: Although the cranes had been identified as a hazard, it appears that the helpers become complacent after wiring over the first two cranes, leading them to become careless with the third. In addition, it appears that the victim misused the lift by climbing up onto the safety railings in order to reach over the beam. The employer should institute a comprehensive safety training program in order to reinforce proper work practices. This program should also include training for the proper use of special equipment, such as the scissor lift which was provided by the site owner,

Recommendation #4: Employers of electrical workers should insure that all workers are trained in basic cardio-pulmonary resuscitation (CPR).

Discussion: One of the most dangerous effects of electric shock is disruption of the natural heart rhythms which may lead to cardiac arrest and death. It is generally recommended that the employers of electrical workers should train their employees in CPR. The timely use of CPR is the only effective first-aid treatment for cardiac and respiratory arrest pending the arrival of advanced life-support personnel.

Diagram

Diagram of incident showing position of scissor lift and workers

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Recommended Resources

It is essential that employers obtain accurate information on health, safety, and applicable OSHA standards. NJ FACE recommends the following sources of information which can help both employers and employees:

U.S. Department of Labor, Occupational Safety & Health Administration (OSHA)
Federal OSHA will provide information on safety and health standards on request. OSHA has several offices in New Jersey that cover the following counties:

Hunterdon, Middlesex, Somerset, Union, and Warren counties
Telephone: (732) 750-3270

Essex, Hudson, Morris, and Sussex counties
Telephone: (973) 263-1003

Bergen and Passaic counties
Telephone: (201) 288-1700

Atlantic, Burlington, Cape May, Camden, Cumberland, Gloucester, Mercer, Monmouth, Ocean, and Salem counties
Telephone: (856) 757-5181

Federal OSHA
Web site: http://www.osha.gov

U.S. Department of Labor, Mine Safety & Health Administration (MSHA)
Federal MSHA regulates safety and health in metal and non-metal mines. The MSHA web site has a great deal of useful safety and health information including detailed reports on fatality investigations. New Jersey mines are under the jurisdiction of the Wyomissing, PA field office.

Telephone: (610) 372-2761
Web site: http://www.msha.gov

New Jersey Public Employees Occupational Safety and Health (PEOSH) Program
The PEOSH act covers all NJ state, county, and municipal employees. Two state departments administer the act; the NJ Department of Labor and Workforce Development (NJDLWD), which investigates safety hazards, and the NJ Department of Health and Senior Services (NJDHSS) which investigates health hazards. PEOSH has information that may benefit private employers.

NJDLWD, Office of Public Employees Safety
Telephone: (609) 633-3896
Web site: http://www.nj.gov/labor/lsse/lspeosh.html

NJDHSS, Public Employees Occupational Safety & Health Program
Telephone: (609) 984-1863
Web site: http://www.state.nj.us/health/eoh/peoshweb/

New Jersey Department of Labor and Workforce Development, Occupational Safety and Health On-Site Consultation Program
This program provides free advice to private businesses on improving safety and health in the workplace and complying with OSHA standards.

Telephone: (609) 984-0785
Web site: http://www.nj.gov/labor/lsse/lsonsite.html

New Jersey State Safety Council
The NJ State Safety Council provides a variety of courses on work-related safety. There is a charge for the seminars.

Telephone: (908) 272-7712.
Web site: http://www.njsafety.org

Internet Resources
Other useful internet sites for occupational safety and health information:

http://www.cdc.gov/niosh - The CDC/NIOSH Web site
http://www.dol.gov/elaws/ - USDOL Employment Laws Assistance for Workers and Small Businesses.
http://www.nsc.org - National Safety Council.
http://www.state.nj.us/health/eoh/survweb/face.htm - NJDHSS FACE reports.
http://www.cdc.gov/niosh/face/ - CDC/NIOSH FACE Web site

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Reference

Code of Federal Regulations 29 CFR 1926, 1989 edition. U.S. Government Printing Office, Office of the Federal Register, Washington DC. pg 162

New Jersey FACE Program

Staff members of the New Jersey Department of Health and Senior Services, Occupational Health Service, perform FACE investigations when there is a report of a targeted work-related fatal injury. The goal of FACE is to prevent fatal work injuries by studying the work environment, the worker, the task and tools the worker was using, the energy exchange resulting in the fatal injury, and the role of management in controlling how these factors interact. FACE gathers information from multiple sources that may include interviews of employers, workers, and other investigators; examination of the fatality site and related equipment; and reviewing OSHA, police, and medical examiner reports, employer safety procedures, and training plans. The FACE program does not determine fault or place blame on employers or individual workers. Findings are summarized in narrative investigation reports that include recommendations for preventing similar events. All names and other identifiers are removed from FACE reports and other data to protect the confidentiality of those who participate in the program.

NIOSH-funded state-based FACE Programs include: Alaska, California, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, New York, Oklahoma, Oregon, Washington, West Virginia, and Wisconsin.

This NJ FACE report is supported by Cooperative Agreement # 1 U60 OH0345-01 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

To contact New Jersey 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.