Inspection Detail

Inspection: 100161546 - Central Foundry Division Of General Motors Corp

Inspection Information - Office: Toledo Area Office

Investigation Summary

AN EMPLOYEE WAS CHANGING A LIGHT BULB THAT WAS NOT IN HIS WORKING AREA. THE EMPLOYEE HAD NO TOOLS OR LOCKS WITH HIM. THERE WERE THREE DISCONNECTS TO OPEN TO DEENERGIZE POWER TO THE HOIST RUNWAY CONDUCTORS IN THE VICINITY OF THE LIGHT BULB. TWO OF THE DISCONNECTS WERE LATER FOUND TO BE OPEN; HOWEVER, THE THIRD WAS NOT. (ALL THE DISCONNECTS WERE MARKED, AND EACH HAS A SCHEMATIC.) THE EMPLOYEE USED A TIGER MANLIFT (AERIAL LIFT) TO GET TO THE WORKING POSITION; BUT, FULLY EXTENDED TO ITS 22-FOOT MAXIMUM, IT WAS TOO SHORT TO REACH THE BULB, WHICH WAS AT A HEIGHT OF 27 FEET, 5 INCHES. THE EMPLOYEE THEN PLACED THE NEW LIGHT BULB ABOVE THE THREE RUNWAY CONDUCTORS. HE WENT BETWEEN TWO OF THE RUNWAY CONDUCTOR RAILS AND GRABBED THEM TO HOIST HIMSELF UP SO HE COULD REACH THE LIGHT. OTHER EMPLOYEES SAW HIM HANGING FROM THE RAILS AND CALLED OUT TO HIM WITH NO RESPONSE. ANOTHER EMPLOYEE SAW THAT ONE OF THE DISCONNECTS WAS STILL CLOSED AND OPENED IT. THE INJURED EMPLOYEE THEN FELL INTO THE AERIAL LIFT. BECAUSE NO ONE COULD FIND THE EMERGENCY VALVE, A THIRD EMPLOYEE CLIMBED THE LIFT AND ADMINISTERED CARDIOPULMONARY RESUSCITATION. IN SPITE OF THESE EFFORTS, THE INJURED EMPLOYEE DIED OF ELECTROCUTION.

Keywords: E GI IV, ELECTRICAL, CPR, ELECTROCUTED, RUNWAY CONDUCTOR, LOCKOUT, AERIAL LIFT