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Occupational Safety and Health Administration OSHA

Inspection Detail

Inspection: 315526442 - City Of Anaheim

Inspection Information - Office: Ca Santa Ana District Office

Nr: 315526442Report ID: 0950631Open Date: 10/27/2011

City Of Anaheim
2540 W. Lincoln Ave
Anaheim, CA 92804
Union Status: NonUnion
SIC: 9131/Executive and Legislative Offices Combined
NAICS: 921140/ Executive and Legislative Offices, Combined
Mailing: 201 S. Anaheim Blvd, Suite 503, Anaheim, CA 92805

Inspection Type:Accident
Scope:Partial Advanced Notice:N
Safety/Health:Safety Close Conference:03/01/2012
Planning Guide: Safety-Manufacturing Close Case:03/12/2012

Related Activity:TypeIDSafetyHealth

Accident Investigation Summary
Summary Nr: 202554127Event: 10/26/2011Inspector Dies Of Burns After Transformer Explosion
On October 26, 2011, a crew was replacing an existing unfused 225 KVA pad mount transformer (PMT) with a new fused 300 KVA PMT. Employee #1, an inspector with the city of Anaheim, was coordinating the sequence of work with the utility control center. The existing overhead feed was to be replaced with a new underground feed for the new transformer. After crew members isolated the existing PMT from the overhead service, they realized that they neglected to identify the phase sequence. A rotation meter was to be used to identify the phase sequence, which required them to reconnect the overhead service. Temporary jumpers were used to reconnect the power from the overhead lines to the pothead feeding the PMT. The foreman was located directly in front of the PMT with an 8-ft hot stick attached to the PMT switch to reenergize the secondary side of the transformer. A coworker was standing on the back side of the PMT, holding the rotation meter that was connected with long leads to the front of the PMT. When the foreman turned on the PMT switch with the hot stick, there was no reading on the rotation meter. The foreman turned off the switch on the PMT and asked the coworker to hold down the button on the meter to enable the reading. When the foreman again turned the on the PMT switch with the hot stick, the PMT exploded. Employee #1 was standing behind the foreman when this occurred. Hot oil spewed out and ignited. Employee #1 was hospitalized at UCI Medical Center for first- and second-degree burns to approximately 15 percent of his body surface involving his face, neck, arms, back, and abdomen. He died seven days later. Employee #1's poor heart condition contributed to his death.
Keywords: burn, electrical testing, fire, lubricating fluid, test equipment, cardiac arrest, explosion, cardiovasc disease, face, transformer
Inspection Degree Nature Occupation
1 315526442 Fatality Other Supervisors; electricians & power transm. install.

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