An employee was standing on a pallet approximately 6 foot off the ground in order to connect a fan to an energized hanging 480v electrical cord. When the employee grabbed the hanging cord, he received a fatal shock and fell to the ground.
The worker was not using appropriate PPE for the task.
The 480v line was not deenergized as required by procedure.
What Can We Learn?
Procedures were in place that require 480v power supplies be deenergized prior to plugging in equipment.
Critical Step Check was not followed. If the S.A.F.E acronym was used the worker could have anticipated the error likely situation and ensure appropriate defenses were in place.
Overconfidence - This employee had done this job before and felt comfortable enough to take this task on alone and without a Lockout or assistance from peers.
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