OSHA Accident Investigation · Summary #14519862
CROWN ZELLERBACH CORP.
ST. FRANCISVILLE, LA·
Event description
ELECTRIC SHOCK - FAILURE OF LOCKOUT SYSTEM
Investigation abstract
A MAINTENANCE ELECTRICIAN WORKING IN A PAPERMILL HAD INSTALLED A DC MOTOR. WHEN THE MOTOR WAS STARTED, IT TURNED IN THE WRONG DIRECTION. THE ELECTRICIAN, WORKIN G ALONE, ENTERED THE ELECTRICAL ROOM TO SWITCH THE CONDUCTORS FOR THE MOTOR IN O RDER TO CORRECT THE PROBLEM. THERE WERE ABOUT 15 SWITCHBOARDS ALONG ONE ROW IN T HE ROOM. THE EMPLOYEE DEENERGIZED THE CORRECT SWITCHBOARD (THE SECOND FROM THE S OUTH END OF THE ROW). HOWEVER, WHEN HE WENT AROUND THE BACK OF THE SWITCHBOARDS, HE REMOVED THE BACK COVER FROM THE WRONG ONE (THE FOURTH FROM THE SOUTH END OF THE ROW). THIS SWITCHBOARD WAS STILL ENERGIZED AT 4160 VOLTS AC. WHEN HE TOUCHED THE ENERGIZED CONDUCTORS, HE WAS ELECTROCUTED.
Victim
-
#1 Fatality Age 59 M
- Nature of injury
- 10
- Part of body
- 4
- Event type
- 13
- Source
- 15
- Occupation code
- 575
- Human factor
- 1
- Environmental factor
- 13
- Task assigned
- 1
Codes shown verbatim from OSHA's accident-investigation database. A human-readable decoder is coming in a future release once the accident_lookup2 dictionary is loaded.