Abstract: On October 12, 2001, Employee #1 was working at the high voltage Motor Control Center at the THUMS Broadway & Mitchell (B & M) Oil Shipping Facility. He arrived at the site at about 12:30 p.m. in response to a trouble call from the Unit Foreman regarding a malfunction at pump #G19. He initially went to the Unit Foreman's office to discuss the problem with him and with the Unit Operator. Employee #1 told them that he wanted to check one thing and left the office; as a result, the Unit Operator did not start the pump. Employee #1 did not tell anyone where he was going, but at approximately 1:05 p.m., three coworkers nearby pump #G19 heard a bang. They went to investigate and saw Employee #1 walk out from the high voltage Motor Control Center and then collapse. The Unit Foreman was immediately contacted and he called Emergency Services. Employee #1 was treated by paramedics but could not be revived. The County Coroner's office confirmed the cause of death as electrocution and reported that "burn" marks were found on his forearms. Subsequenet investigation revealed that Employee #1 was injured approximately 8 to 10 minutes after leaving the Unit Foreman's office. The outer and inner doors of the #G19 motor control center were found open immediately after the accident and the #G19 motor controller was energized. According to the employer, the inner door interlock was not working after the accident. Employee #1 was not wearing any high voltage gloves nor were any approrpiate hazard gloves found at the scene. In addition, he did not have a "hot stick," or voltage tester with him, and he was working alone near high voltage equipment.