Abstract: On October 19, 2002, Employee #1 was working at a steel manufacturing facility in Norfolk, NE, that was in the process of switching electrical equipment to new transformers. At approximately 7:45 p.m., he entered the electrical room housing the controls, equipment, and switchgear for transformer RT3/RT5 and several DT controls. He performed several tasks in the sequence of establishing and getting RT3 switched to the new designation of RT5. Employee #1 went behind the panel of switchgear and began to remove the back cover to DT3. This switchgear was four units from where he should have been behind RT3. Employee #1 was removing the back cover to DT3 and had pulled it out to a resting position on a temporary angle support 10 to 12 in. from the back of the cabinet. He then reached on top of the cabinet to grab a battery-operated drill to remove the bolt holding the back cover of DT3. He secured the drill and was moving it forward to his position when the battery became loose and dropped inside the switchgear cabinet. Employee #1 reached into the cabinet with his left hand and was retrieving the battery when the drain wire on the center phase pole was pulled loose. It whipped into the air and struck the top phase pole #1, causing an arc flash. Employee #1 suffered electrical burns over 24 percent of his body, including his face, shoulder, upper trunk, arms, and hands. Subsequent investigation determined that he had failed to lockout the DT3, and it was energized at the time of the accident.