Abstract: A THREE-MAN, SUBSTATION MAINTENANCE CREW WAS REPLACING A WORN 15-KILOVOLT, 600-AMPERE ELECTRIC DISCONNECT SWITCH. THEY HAD BEEN THOROUGHLY BRIEFED BY THEIR SUPERVISOR ON THE CORRECT PROCEDURES TO ACCOMPLISH THE TASK. THE POWER HAD BEEN SWITCHED FROM THE WORN DISCONNECT AREA TO THE TRANSFER BUS SO THEY COULD DO THE WORK SAFELY. GROUNDS HAD BEEN INSTALLED AND ALL LADDERS HAD BEEN SECURED. ONE OF THE EMPLOYEES HAD HIS LADDER BETWEEN THE FIRST TWO DISCONNECT SWITCHES. HE WAS TO DISCONNECT THE LEADS FROM THESE TWO SWITCHES, THEN MOVE HIS LADDER TO HIS LEFT NEAR THE THIRD SWITCH, AND THEN CLIMB UP AND REMOVE THE LEADS. WHEN HE FINISHED THE FIRST TWO DISCONNECTS, HE CLIMBED UP ON THE STEEL, INSTEAD OF MOVING HIS LADDER, TO REMOVE THE THIRD SWITCH. IN SO DOING, THE BACK OF HIS SHOULDERS CONTACTED THE 7200-VOLT TRANSFER BUS AND KNOCKED HIM TO THE GROUND, A DISTANCE OF ABOUT 17 FEET. HE SUFFERED SEVERE ELECTRICAL BURNS AND VARIOUS CONTUSIONS AND ABRASIONS FROM THE FALL. HE LATER DIED AS A RESULT OF HIS INJURIES.