From the Files of NIOSH: Disregard for Lockout/Tagout Results in Death

May 15, 2009
Disregard for established lockout/tagout procedures is not only risky, but it can also be fatal, as was evidenced by the death of an electrician at a California newspaper recycling factory.

Disregard for established lockout/tagout procedures is not only risky, but it can also be fatal, as was evidenced by the death of an electrician at a California newspaper recycling factory. The factory had been undergoing renovations, with replacement and repair of the steel beams in the walls, floors, and ceilings of the mill building's third floor. The victim, a 43-year-old male, was electrocuted while repairing a lighting circuit damaged by the contractor performing the renovations.

The day prior to the accident, the decedent and several of his coworkers had re-routed the electrical circuits still in use so that the contractor could perform his work. The electrical circuits were located at the ceiling level of the second floor. On the day of the incident, the contractor was working around a steel beam at floor level on the third floor when he inadvertently cut a conduit with an energized line used for lighting on the second floor. The lead electrician for the company assigned the victim the task of repairing this line, instructing him to “kill the circuit” at the junction box and repair the damaged wiring.

The lead electrician was working in the same area but did not have visual contact with the victim. After completing his work, the lead electrician went to the storeroom for parts. Upon his return (approximately 20 min. later), he decided to check on the victim, whom he found unconscious and nonresponsive on a scaffold platform. He immediately radioed for help while other employees performed CPR on the victim. Once on the scene, paramedics and the fire department, found the electrician without a heartbeat, and intubated him. Then, they transported him to a local hospital, where he was pronounced dead.

After the victim was removed from the accident scene, the employer and local police performed a preliminary investigation. They found the victim's pliers that were used for stripping electrical wire still attached to a wire from the damaged circuit at ceiling level. Closer inspection showed burn marks on the pliers and a pipe, indicating contact was made at these points. The physical evidence suggested the victim had ascended the contractor's scaffold and then climbed onto a piece of machinery to gain access to the damaged lighting circuit. While the victim was working on the energized circuit, his pliers made contact with the pipe, completing the circuit and electrocuting him. It is not known how long he remained in contact with the energized system. It appears that when the electrical breakers finally tripped, cutting off the electrical current to the circuit, the victim fell from the machinery and landed on the scaffolding planks below, where he was discovered by his supervisor.

An inspection of the junction box where the circuit breakers were housed determined that the circuit had not been manually turned off or locked out and tagged prior to the commencement of work. The circuit had been tripped when the victim made contact with the energized line. The victim's circuit tester, which was intended to be used to verify that a circuit has been de-energized before work begins, was found in his locker after the incident. The cause of death, according to the death certificate, was electrocution.

Although the employer in this case had a lockout/tagout program, it was not being used when the victim was working on the energized lighting circuit that was damaged by the contractor. Had the victim followed the company's policy and procedures, this incident might have been prevented. To avoid similar tragedies, NIOSH recommends the following:

Ensure workers follow established lockout/tagout procedures for control of hazardous energy when working on electrical circuits.

Reprinted with permission from the National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR). View all electrical-related FACE reports in their entirety.

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