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Factory Manager Bypasses Lockout/Tag-out and is Electrocuted

Kentucky Case Report: 14KY031
Release Date: October 17, 2014

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 June 11, 2014, a 37-year-old factory manager and married father of three was called to check on a 5 blade multiple trim saw. Two employees reported that the saw was not working properly. The victim walked to the electrical panel box and failed to de-energize the saw by properly shutting down any hazardous energy. He did not lockout, tag-out, and verify hazardous energy shut down before servicing the saw. The victim reached into the energized electrical panel box to reset a relay and came into contact with 480 volts of electricity. This shock was powerful enough to send him into cardiac arrest. The employees who were working on the saw immediately turned around and discovered the victim lying unconscious on the ground. One employee called 911 at 11:45 am, while the other employee performed CPR. EMS arrived at 11:56 am and the victim was transported to the local hospital, where he was pronounced dead.

Factory Manager Bypasses Lockout/Tag-out and is Electrocuted [PDF 1.47 MB]