Fatality Assessment and Control Evaluation (FACE) Report for Massachusetts: Electrician Electrocuted While Troubleshooting Envelope Manufacturing Machine, FACE-12-MA-007-01

摘要

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. The Massachusetts FACE Program concluded that to prevent similar occurrences in the future, employers should: (1) Ensure that electrical circuits and equipment are de-energized and that lockout/tagout standard operating procedures are implemented and enforced prior to beginning work; (2) Provide and ensure that employees use appropriate personal protective equipment (PPE) and tools for troubleshooting live circuits; (3) Develop, implement, and enforce an Injury and Illness Prevention Program that addresses hazard recognition and avoidance of unsafe conditions; and (4) Ensure that work is scheduled to allow for sufficient rest periods between work shifts. In addition, machine manufacturers should implement the concept of Prevention through Design (PtD) to ensure the safety and health of machine users, including machine operators and maintenance workers.