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Maintenance worker electrocuted while attempting to change a light bulb in Washington State.

Washington State Department of Labor and Industries
Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 04WA080, 2008 Jul; :1-27
In October of 2004, a 32-year-old male maintenance worker died from electrocution while working at an assisted living facility in Washington State. The victim was changing a broken metal halide bulb in a ceiling fixture. To remove it, the victim turned off the area wall light switch and taped the switch in the "off" position. The victim climbed into the attic space and detached the fixture "light can" to remove the broken bulb. While holding on to the fixture in one hand, he touched the bulb base with a non-insulated tool and was electrocuted. The fixture was still hot (energized). It was part of a building emergency lighting system on a separate circuit. The wiring was not shown in the "as-built" plans he was using and it was not connected to the breaker. Between 1:00 PM to 1:30 PM, co-workers noticed the victim was missing and conducted a search. They were unable to find him and called 911. The local fire department, rescue team eventually found the victim -- deceased in the second floor ceiling location of the building. The employee was not trained or authorized to do electrical work; neither was he experienced in changing metal halide bulbs which often are difficult to remove. To prevent similar occurrences in the future, the Washington State Fatality Assessment & Control Evaluation (FACE) investigative team advises facilities maintenance employers to follow these guidelines: 1.) Only qualified electricians should work on electrical systems. 2.) Proper Lockout-Tagout procedures should be used when work is done on any system that may contain electrical energy. 3.) Electrical systems and components must be tested to ensure they are de-energized before performing work. Turning off a light switch or circuit breaker may not de-energize an electrical system or its components. If you can't test, let it rest. 4.) Tools for de-energizing circuits should not be supplied to untrained personnel. Make sure appropriate testing devices and insulated tools are used and verify that personnel are knowledgeable and trained in their safe operation. In most cases it is recommended that a licensed electrician perform the testing. 5.) Don't rely on "as built" electrical drawings to determine current electrical system design and operation. Systems must be verified in place by testing and tracing the actual configuration. 6.) The facility accident prevention guidelines for these types of lighting systems should describe this electrocution hazard for maintenance personnel. 7.) Electrical breakers should be clearly labeled to indicate their action, location, and purpose.
Region-10; Accident-analysis; Accident-potential; Accident-prevention; Accidents; Electrical-hazards; Electrical-industry; Electrical-properties; Electrical-systems; Electrical-workers; Electrocutions; Injuries; Injury-prevention; Job-analysis; Occupational-health-programs; Occupational-safety-programs; Protective-equipment; Safety-education; Safety-equipment; Safety-measures; Safety-practices; Training; Traumatic-injuries; Work-analysis; Work-environment; Worker-motivation; Work-operations; Work-performance; Work-practices
Publication Date
Document Type
Field Studies; Fatality Assessment and Control Evaluation
Funding Type
Cooperative Agreement
Fiscal Year
NTIS Accession No.
NTIS Price
Identifying No.
FACE-04WA080; Cooperative-Agreement-Number-U60-OH-008487; Cooperative-Agreement-Number-U60-CCU-013928
Priority Area
Agriculture, Forestry and Fishing
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Washington State Department of Labor and Industries
Page last reviewed: September 25, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division