Inspection Detail

Inspection: 310493804 - Amcor Pet Packaging Usa Inc

Inspection Information - Office: Long Beach District Office

Investigation Summary

At approximately 2:05 a.m. on December 09, 2008, Employee #1 a senior maintenance mechanic Amcor Pet Packaging Usa Inc, was performing a regularly assigned task of replacing an electrical component in the attempt to repair a production machine. Employee #1 was assigned the task of determining the problem causing a blow molding machine to not function properly. Employee #1 determined that the machine lamp cooling fan motor was over-heating and tripping the motor circuit breaker. Employee #1 deenergized the machine and went to look for spare parts. Spare parts could not be located. Employee #1's supervisor told him to disconnect the cooling fan motor relay and they would try to run the machine without the fan. Employee #1 disconnected the cooling fan motor at the panel relay and reenergized the machine control panel and waited for a machine operator to start the machine so they could see if the machine would operate without the cooling fan motor. The control panel door was still open at that time and Employee #1 observed that one of the wires that he had disconnected was close to another wire and he decided it would be better if the wires were farther apart. While the control panel was still energized the Employee #1 moved the wire with a screwdriver. While moving the energized wire Employee #1 inadvertently moved the energized wire into another energized wire he had disconnected causing a phase-to-phase short circuit that resulted in an electric arc flash. The arc flash from the 380-volt (nominal) line circuit, caused second and third degree burns to his hands and face at the time Employee #1 was not working within close proximity to any other coworkers. Employee #1 was transported by the employer to U. S. Health Works and then transferred and admitted to Sherman Oaks, Grossman Burn Center for four days. The supervisor for Employee #1 was in his office at the time of the incident. Interviews were conducted of Employee #1 and the plant manager. The investigation concluded that Employee #1 did not follow established energy control procedures that the employer had in place. Employee #1 was an experienced nonsupervisory senior maintenance mechanic and was aware that his actions were in violation of company policy. The facility involved in the incident was a blow molding plastic bottle manufacturer with 143 employees. Employee #1 had been working there for eleven years, performing duties of a senior maintenance mechanic, including repairing production machinery.

Keywords: BURN, ELECTRIC ARC, ELECTRICIAN, ELECTRICAL WORK, ELECTRICAL CABINET, ELECTRICAL FAULT