Abstract: A CREW OF EMPLOYEES WAS CLEANING AND SERVICING POWER DISTRIBUTION EQUIPMENT IN THE SUBSTATION OF A HOSPITAL. THE EQUIPMENT WAS DEENERGIZED BUT WAS NOT ISOLATED OR TESTED FOR VOLTAGE. THE EQUIPMENT INVOLVED WAS A 1000 KILOVOLT-AMPERE TRANSFORMER (NIAGARA, SERIAL NUMBER 49605). TWO EMPLOYEES FROM THE CREW WERE CLEANING AND WAXING INSULATORS ON THE TRANSFORMER. DURING THE COURSE OF THIS WORK, ONE OF THEM STAGGERED BACKWARDS AND THEN STARTED TO FALL FORWARDS. AS HE DID SO, TWO EMPLOYEES GRABBED HIM AND LOWERED HIM TO THE FLOOR. THE INJURED EMPLOYEE DIED, AND IT WAS THOUGHT AT THE TIME THAT HE HAD SUFFERED A HEART ATTACK. HOWEVER, THE CORONER RULED THAT HIS DEATH WAS CAUSED BY ELECTROCUTION. IT WAS DETERMINED THAT VOLTAGE BACKFEED ENERGIZED THE CIRCUIT TO THE TRANSFORMER. THE EMPLOYEE HAD BEEN STANDING WITH HIS CHEST AGAINST A GROUNDED PART OF THE ENCLOSURE AND HAD PROBABLY CONTACTED ENERGIZED PARTS OF THE TRANSFORMER WHEN HE WAS ELECTROCUTED.