Fatal Accident Circumstances and Epidemiology (FACE) Report: Journeyman Electrician Electrocuted When Lockout Attempt Fails, December 17, 1988

摘要

A 39 year old male journeyman electrician died when, after deenergizing one controlled access area, he mistakenly entered an identical energized area through a hatch with a defective lock, and made contact with an energized conductor. The employer, a large pulp and paper mill, has a full time safety and health officer, a written safety policy and detailed safety procedures. The victim had been employed there for the past 12 years as a journeyman electrician. At the time of the incident the paper mill was in the middle of a scheduled shutdown during which time the mill operation ceased by 50%. The victim and a coworker were engaged in routine maintenance and inspection of an electrostatic precipitator in a large recovery boiler. The transformers controlling the precipitators were located inside two 25 foot by 37 foot high precipitator penthouses. The only access was through separate 24 inch diameter access hatches located on the roof. The company used a sophisticated captive key lockout system to control access to the penthouses. The victim had successfully locked out transformers 1, 3, and 5. To obtain the needed key to the penthouse he would have had to travel down the steps from the eighth floor to the first floor, obtain the key and returned to the eighth floor. He commented to the coworker that the lock to the penthouse hatch was broken and that they could save themselves the trip by entering the hatch. The coworker asked twice whether the area was safe. The victim replied that it was, entered the hatch, and was electrocuted. It was recommended that periodic safety inspections be made to be certain all equipment was in working order.