FATALITY ASSESSMENT AND CONTROL EVALUATION (FACE) PROGRAM
Electrician Electrocuted while Troubleshooting Envelope Manufacturing Machine - Massachusetts
Massachusetts Case Report: 12MA007
Release Date: October 30, 2013
The following report is the product of our Cooperative State partner and is presented here in its original unedited form from the state. The findings and conclusions in this report are those of the individual Cooperative State partner and do not necessarily reflect the views or policy of the National Institute for Occupational Safety and Health.
On April 4, 2012 a 53-year-old male electrician (victim) was electrocuted while troubleshooting a medium open-end envelope machine. The machine’s blower was not working and the victim was working to repair it. The victim was reaching into the machine to access wiring for the blower contained in an electrical junction box when he was electrocuted. A co-worker noticed the victim was not moving and grabbed the sleeve of his shirt and pulled him away from the machine. The co-worker then yelled for help and another co-worker called emergency medical services (EMS). The local fire department was on site to inspect the sprinklers and were summoned and started to care for the victim. The local police and then the state police arrived at the incident location. The victim was transported to a local hospital where he was pronounced dead.
Contributing factors identified in this investigation included a lack of comprehensive standard operating procedures for lockout/tagout as part of an overall hazardous energy control, the location of the machine’s electrical junction box that was both physically and visually inaccessible, and the victim working extended hours to limit the disruption of production.