California NURSE Project

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A self-employed electrician was hired by a turkey plant to install an icemaker. The electrician began the job a day before anyone at the factory expected him. The maintenance workers at the factory had not been told to turn the power off that morning, and the electrician did not report to anyone at the factory before beginning work.

The electrician took off the cover of an electrical junction box, where factory equipment can be connected to a 440 volt power supply. Without testing to see if the power to the box was shut off, and without putting on his insulated gloves and face shield, the electrician touched a live connection and set off an electrical flash so strong that he thought the box had exploded. He was burned on the face, neck, chest, arms, his hair was burned off, and his fingerprints were found burned to the panel box. He died five days later from the burns.

How could this death have been prevented?

• If the electrician and the factory had followed a schedule so that maintenance and safety workers at the factory would know when he was working;
• If the electrician had followed the factory's safety program, which includes rules for disconnecting power and making sure it cannot be reconnected
• If the electrician had checked that the power was off at the junction box;
• If the electrician had his own written safety program and standard operating procedures

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NASD Review: 04/2002

This document, CDHS(COHP)-FI-92-005-01 , was extracted from a series of the Nurses Using Rural Sentinal Events (NURSE) project, conducted by the California Occupational Health Program of the California Department of Health Services, in conjunction with the National Institute for Occupational Safety and Health. Publication date: May 1992.

The NURSE (Nurses Using Rural Sentinel Events) project is conducted by the California Occupational Health Program of the California Department of Health Services, in conjunction with the National Institute for Occupational Safety and Health. The program's goal is to prevent occupational injuries associated with agriculture. Injuries are reported by hospitals, emergency medical services, clinics, medical examiners, and coroners. Selected cases are followed up by conducting interviews of injured workers, co-workers, employers, and others involved in the incident. An on-site safety investigation is also conducted. These investigations provide detailed information on the worker, the work environment, and the potential risk factors resulting in the injury. Each investigation concludes with specific recommendations designed to prevent injuries, for the use of employers, workers, and others concerned about health and safety in agriculture.