Inspection Detail

Inspection: 1473145.015 - Monogram Prepared Meats

Inspection Information - Office: Iowa 0751910

Investigation Summary

At 7:30 p.m. on April 6, 2020, an employee was working for a firm that prepared meat from carcasses. He was the maintenance supervisor. He was working in the firm's upstairs transmitter room. The narrative said the equipment being worked on was microwave equipment, but that was not correct. The power was being generated in the ultrasound region, at 73 kHz, as a form of non-thermal food-processing technology. The employee was troubleshooting inside the transmitter's electrical cabinet. Parts within were energized at a variety of voltages. The electrical cabinet was supplied with three-phase 480-volt AC power, and some parts inside were energized at that level. The cabinet also contained parts energized at DC voltages from 12 volts DC to 18,000 volts DC. Finally, the 73 kHz ultrasound power was present inside the cabinet. The employee was using a Klein Tools CL1000 clamp-on multimeter. To keep from disrupting production, the employee had not electrically locked out the cabinet. He was relying on the door interlock to keep the power from coming on. The electrical interlocks on the cabinet had been disabled, however, so that videos could be made of arcing inside the cabinet. They had never been restored to a functioning condition. The employee was attaching the meter to check for amperage, unaware that someone on the line downstairs had hit the start button, energizing parts inside the cabinet. The employee's left elbow and right forearm made direct contact with energized parts. He received an electric shock and burns to his left elbow and right forearm. A coworker found him lying on the floor. CPR was initiated, and emergency services were called. The employee was life flighted for treatment. He was hospitalized. The employee had not received training in safe electrical work practices, working alone, the use of PPE such as rubber insulated gloves or arc flash protection, grounding, or lockout/tagout. The equipment had been scheduled for replacement since December 2019.

Keywords: CPR, E GI IV (no lockout), Elbow, Elec Protect Equip, Electric Arc, Electric Arc Flash, Electric Shock, Electric current, Electrical, Electrical Box, Electrical Burn, Electrical Cabinet, Electrical Testing, Electrical Work, Electrical panel, Electronic Equipment, Electronic Technicn, Electronic Work, Emergency Response, Energized, Food processing, Forearm, Inadequate Maint, Insulated Tool, Interlock, Lockout, Lockout/Tagout, Misjudgment, Misjudgment of Hazardous Situation, PPE, Skin, Test Equipment, Testing, Training, Work Rules, Working Alone