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Jon Pina. MS CSP

Case Synopsis:

The contracted scaffolding crew came on in the evening to remove the scaffolding from a ten story boiler of a southern paper mill that they had installed at the beginning of a scheduled outage. The boiler tubes had been inspected and the management of the mill gave the order to remove the scaffolding and prepare for startup.

At midnight five men had removed scaffolding down to the 6th floor and entered the boiler through a 15" manhole. Shortly after entering to continue dismantling and climbing up to the 7th floor and removing the scaffolding poles and planks a worker came in contact with a broken light bulb of a light stringer and began to scream for 45 seconds until someone outside the manway, acting as a confined space attendant unplugged the extension cord that powered the light stringer. Working in the dark, two of the four remaining workers began CPR to no avail. A fire department, acting as the confined space rescue squad, was summoned and removed the electrocuted worker's body.

At the same time the fatal shock was occurring, the victim was attempting to pass a scaffold pole to another worker to pass it on and out through the manway when he struck another existing scaffold pole, causing current to energize it. Unfortunately, a scaffold remover near the 6th floor manway on the scaffold planks beneath the victim contacted an energized pole in place and received a severe shock as the current passed through his shoulder and grounded into the boiler tubes that he also contacted in the tight working space. Five years later he died as well. Medical reports revealed his heart had continued to scar after the shock, resulting in heart failure.

The scaffolding consisted of 12" wide planks that were mounted on telescopic poles with shelf-like horizontal brackets. The working/walking surface was only 13" wide. There were only 3 floors in the 10 story boiler with manways to enter. The scheduled outage was during the month of August. The working environment was very hot and dark in addition to the tight working quarters.

Expert Analysis:

The light stringer had been plugged into a non-GFCI receptacle. A ground fault circuit interrupter (GFCI), designed to trip at 6 to 7 milli-amps is a requirement for all 110 volt circuits in the construction according to OSHA. GFCI receptacles are installed in the bathrooms and kitchens of homes due to the presence of water sources. An outage of a mill is considered construction by OSHA and falls under 1926 versus the 1910 General Industry standards when in operation. OSHA cited the owner and general contractor for the following electrical violation:

1926.405(a)(2)(ii)(E) All lamps for general illumination shall be protected from accidental contact or breakage. Metal-case sockets shall be grounded.
a. Employees working inside the #3 Recovery Boiler were exposed to the hazard of contacting an energized light bulb receptacle.
1926.405(a)(2)(ii)(G) Portable electric lighting used in wet and/or other conductive locations, as for example, drums, tanks, and vessels, shall be operated at 12 volts or less. However, 120-volt lights may be used if protected by a ground-fault circuit interrupter.
a. Employees working inside the #3 Recovery Boiler were exposed to the hazard of contacting exposed electrical conductors on damaged electrical cords.
1926.405(j)(1)(i) Live parts. Fixtures, lampholders, lamps, rosettes, and receptacles shall have no live parts normally exposed to employee contact. However, rosettes and cleat-type lampholders and receptacles located at least 8 feet (2.44 m) above the floor may have exposed parts.
a. Employees working inside the #3 Recovery Boiler were exposed to the hazard of contacting exposed electrical conductors on damaged electrical cords.

The mill management provided a GFCI panel but it was found to be disconnected during the accident investigation. The non-GFCI receptacle, located near the 6th floor manway, that the light stringer was mistakenly plugged into, should have been locked out via the circuit breaker. Over thirty individuals were deposed and no one admitted to any knowledge of who plugged the light stringer into the non-GFCI receptacle. It was likely that someone may have absent-mindedly plugged it in and not remembered since it was not treated as a safety "priority" and carefully checked by "competent persons" that were in supervisory roles.

Additionally, no one admitted to owning or providing a 3-bulb modified light stringer with frays and plastic bulb covers that allowed the victim to contact the broken bulb, located on the end of the stringer. Since there was no additional lighting, it was virtually impossible to see the broken bulb with only 2 lights working on the stringer.

OSHA also issued citations for confined space violations, mainly for failure to properly train rescue personnel. However, even the best rescue efforts would not have prevented the electrical shocks that resulted in two fatalities. The mill management attempted to place all of the responsibility on the general contractor and contractors. The mill was a producer of electricity as a byproduct and was aware of the hazards of electrical shock potential and the means of protecting workers from those hazards. They had supervisors that observed what the contractors did on all shifts and that placed them in the construction manager status.

According to OSHA emphasis initiatives, construction is a very high hazard industry. By simply developing an excellent "safety culture" one can drastically reduce the majority of accidents. This can be accomplished by following a written safety and health program, which entails conducting "toolbox" safety meetings, inspections, training, engineering controls, safe work practices, a "competent person", multi-employer worksite directives, and employee accountability. Failure to establish and maintain a written safety and health program generally results in a working environment that can be deemed unsafe for all parties on site. It is often said that "failing to plan is planning to fail", yet unfortunately, this scenario is repeated over and over throughout the construction industry, as safety falls by the wayside to costs and schedule emphases. Although many contractors are fortunate and do not experience adverse consequences as that which occurred during this mill outage others are less propitious and the result is often litigation.


Fortunately, the long and drawn out case was settled with a favorable settlement for the survivors of the plaintiffs. The fact that the second victim died could have had negative results for the plaintiff survivor's without his testimony had it gone to trial.

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Jon Pina, MS, CSP, is a Safety, Health, & Environmental Expert. With more than thirty years experience in safety management, loss prevention, construction and demolition, coal, chemical, steel, and hazardous waste abatement, Mr. Pina can observe cases from a well-rounded viewpoint of a Safety and Health professional, construction manager, and "hands on" worker. Among his most notable accomplishments, he has held the position of Construction Manager on many large-scale demolition projects. He also has demonstrated expertise in areas such as the operation of chemical plants and gained field experience as a union journeyman pipe fitter.

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