Employee Electrocuted While Dismantling a Metal Edged Box Resting on a Flexible Electrical Cord

FACE-91-07
DATE: July 23, 1991

SUMMARY

A 24 year old white male wind-up operator was electrocuted when the metal edge of a box he was dismantling severed the insulation on a flexible electrical cord. The box had apparently fallen off the fork lift and was propped on edge by the fork lift which was not operation at the time of the incident. He was breaking off bolts with a hammer and chisel; the weight of the box and the force of the blows exposed the energized electrical wire. The company electrician measured 277 volts and .1 amps subsequent to the fatality. The employee had been breaking apart these metal framed wooden boxes because they were no longer needed by the company. He had been working for 11 hours and forty-five minutes when this fatality occurred. Massachusetts Department of Labor and Industries investigators concluded that, in order to prevent future similar occurrences, employers should:

• refrain from using flexible electrical cords as a substitute for fixed wiring
• refrain from using flexible electrical cords where they may be subjected to damage
• ensure that established safety procedures are followed at all times
• discourage the practice of 12 hour work days to avoid employee fatigue
• ensure that the company safety program is comprehensive and includes identification of common electrical hazards.

INTRODUCTION

On April 24, 1991, a 24 year old white male was electrocuted when the metal edge of a storage box he was dismantling cut through the insulation on an energized extension cord beneath it. The local police notified the Department of Labor and Industries via the Occupational Fatality Hot Line on April 25, 1991. On May 3, 1991 inspectors from the Department conducted an investigation including photographs of the site of the fatality. Local police and OSHA also conducted investigations.

The employer in this incident is an automobile accessories manufacturer that has been in business for 68 years. This company employs 205 full-time employees in the production of vinyl and rubber coated product for automobile. The victim had worked for three and a half years. The company has a full-time safely director and reported that they hold weekly safety meetings, complete daily safety check lists and sponsor a safety committee that insets the workplace.

INVESTIGATION

On the day of the incident, the victim was breaking down wooden boxes, measuring 8′ by 2′ by 2′, which had previously been used to store embossing rolls. The storage bo had a steel edging or frame with an axle on each side where wheels were attached as well as metal slots for the forks of a fork lift. The boxes were being dismantled because they were no longer needed. The victim had been working since 6:20 a.m. This accident occurred at about 6:05 p.m. At the time of the police investigation, the box was observed to be lying at an angle, on one mental edge, propped in this position by the fork lift, with the forks approximately two feet off the ground. The victim, whose job title was wind-up operator and inspector, was breaking off the bolts that secured the angle irons around the storage box with a small chisel and steel mallet. The weight of the box edge on the extension cord broke off the insulation exposing the energized wire. The current passed from the 277 volt, 0.1 amp line through the metal frame and chisel or hammer, through the victim’s body to the ground or back to the source.

A worker passing the victim’s work location observed him lying on his back and called for help. Responding to the call were the local fire and police department vents as well as advanced life support paramedics from a nearby hospital. Assistance arrived within 4 minutes of the telephone call. CPR was given by paramedics from the fire department and local hospital; they suspected cardiac arrest. He was transported to the hospital, but was declared dead on arrival.

The police officers investigation this “sudden death” wrote that the victim’s body was lying on top of an extension cord that ran from and outlet on top of a fabric pressing machine, under the victim’s body, under the propped up box on which the victim had been working to a rolling machine. A company electrician measured 277 volts and 0.1 amps. The extension cord was kept by the police as evidence.

CAUSE OF DEATH

To be completed upon receipt of autopsy.

RECOMMENDATION/DISCUSSION

Recommendation #1: Flexible electrical cords should not be used as a substitute for fixed wiring.

Discussion: In this situation, it was reported that a flexible extension cord was plugged into an outlet an the Gessner pressing machine and to a rolling machine across the aisle. Although this had been set-up as a temporary solution, it had remained this way for a long period of time (years). This is prohibited by OSHA (OSHA 29 CFR 1910.305 (g)(iii)); flexible cord or cable shall not be used as a substitute for fixed wiring. It is also prohibited by the National Electrical Code (NEC Article 400-8).

Recommendation #2: Flexible extension cords should not be used where they may be subjected to damage.

Discussion: Even as a temporary solution this flexible cord was extended across a aisle, passageway or work area. It may have caused a tripping hazard and was subject to mechanical damage as fork lifts transported material over the cork. Ultimately, the sharp metal edge of the frame of the box severed the insulation causing a fatal electrical hazard.

Recommendation #3: Employers should ensure that established company safety procedures are followed at all times.

Discussion: Management should re-affirm the necessity of following established safety procedures with all supervisors. This company has a full-time safety supervisor, weekly safety meetings and daily safety check lists. Compliance with OSHA regulations and NEC requirements should be part of regular inspections, check list and safety meetings.

Recommendation #4: Employers should consider the effects of extended workdays on accidents, injuries and errors, and implement an 8 hour work day where possible.

Discussion: This fatality occurred almost twelve hours after the work shift had begun at 6:20 a.m. Research has indicated that fatigue adversely affects human performance, decreases alertness and vigilance, increases error frequency, increases near-miss events, etc. This may be due to extended work hours, or less time off between consecutive shifts. It is not known in this fatality whether fatigue may have contributed to the incident. However, employers should ensure that work schedules promote health and safety considerations and vigilance.

Recommendation # 5: Employers should ensure that the safety program is comprehensive and includes identification of common electrical hazards.

Discussion: Employers should conduct through work site surveys to identify potential hazards to workers. Once potential hazards have been identified, appropriate control measures can be implemented. In this case, the long term use of a flexible cord across a work area could have been identified as a violation of OSHA and NEC and a hazard that needed to be corrected.

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