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:
- Only qualified electricians should work on electrical systems.
- Proper Lockout-Tagout procedures should be used when work is done on any system that may contain electrical energy.
- 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.
- 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.
- 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.
- The facility accident prevention guidelines for these types of lighting systems should describe this electrocution hazard for maintenance personnel.
- Electrical breakers should be clearly labeled to indicate their action, location, and purpose.
- The incident being reviewed by FACE took place at an assisted living facility located in southern Washington State. This facility is a sub-unit of a much larger organization with several facilities located in the Northwest region. Each site is set up as an individual LLC (limited Liability Company).
- The parent company is headquartered out of state and employs over 1,000 people. The company manages over 2,300 apartments and housing units in multiple states.
- The organization’s staff positions include site administrators, activity directors, housekeepers, nurses, caregivers, cooks, dietary aides, licensed practical nurses (LPN/RCCs), and maintenance personnel.
- The company started in 1979 as a construction company and then transitioned through real-estate sales and development, before evolving into its current senior living operations business in 1995.
- The facility where the incident occurred was opened in 2001 and employed 38 people at the time of the incident, including the victim.
- The facility administrator has many duties including safety of the site. The facility maintenance employee (the victim) reported to the facility administrator.
- The organization had written safety processes in place, but the FACE team was not able to evaluate the scope and effectiveness of their safety program.
- The facility had a written process for handling general electrical issues and also had a Lockout-Tagout process in place.
- It is not clear how well these safety guidelines were understood by the facility administrator or the victim. Our investigation indicates that the victim had some knowledge of proper safety procedures when working with the facility’s lighting system; however, there were elements of the process that were either missed or not clearly defined or understood by the victim.
- The facility had a safety committee, but the FACE investigation team was not able get any details of its processes.
- It is also not clear how much experience the victim had in performing facility electrical work. As the maintenance person, it appears the victim was more of a generalist, having the skills to perform a wide variety of maintenance work for the facility, but for more complex maintenance issues would be expected to request external help, such as a contractor.
- For most organizations, hiring a contractor needs the approval of the site facility administrator and sometimes the parent organization, depending on the cost of the work required. This might make a maintenance worker reluctant to ask for outside help.
- Changing a light bulb should be an easy task for any maintenance person, but there are hidden hazards when dealing with electrical system maintenance and repair. Electrical system work should only be done by a qualified or certified person.
- The victim had worked for this employer for approximately five months prior to the fatal incident. Previously, the victim worked as a maintenance supervisor for an auto dealership. He had also previously worked as an auto mechanic.
- On a Tuesday morning in October of 2004, the victim was electrocuted when he made contact with an exposed energized metal halide light conductor and a grounded item.
CLICK HERE (pdf) for the FULL FACE REPORT from WA-OSHA.
