Date of incident: November 2014
Notice of incident number: 2014170000038
Employer: Electrical utility

Incident summary
An electrician was working from a ladder, installing linkages onto a set of three circuit breakers in a substation. After completing the task, he attempted to remove his temporary fall protection anchor strap from the steel beam where he had placed it. In the process, he lost his balance and instinctively reached out and grabbed an energized 12 kV (high-voltage) busbar. He received an electrical shock, lost consciousness, and fell from the ladder into his fall protection harness. He was seriously injured.

Investigation conclusions
Cause

• Contact with an energized busbar: When the electrician lost his balance, he grabbed the energized busbar. He remained in contact with the energized busbar for about five seconds and received severe burns.

Underlying factors

• System not de-energized: Contrary to the employer’s safety management plan, the system was not de-energized despite the fact that de-energization would have been practicable.
• Violation of limit of approach: The electrician was working on circuit breakers that were outside his limit of approach (the distance he was required to maintain between himself and the breakers). However, he violated his limit of approach to the energized busbar when he placed his temporary fall protection anchor strap on a steel beam and then later removed it. Placement of temporary anchors was left to the discretion of workers at this worksite, which raised the risk of violating limits of approach.
• Use of ladder instead of work platform: The electrician used an extension ladder to access the circuit breakers even though the type of work he was doing made it virtually impossible to maintain three-point contact. If he had been using a scaffold or some type of elevating work platform, he would have been protected by guardrails. A work platform would also have provided a fall protection anchor point. He would not have had to attach the temporary fall protection anchor to the steel beam, and so would not have violated his limit of approach and come into contact with the energized busbar.

Other safety issue

• Lack of rescue procedures: There were no adequate written work or rescue and evacuation procedures even though such procedures are required by the Occupational Health and Safety Regulation for work at high angles. Thus, there was no plan for rescuing a worker who had received an electric shock and fallen unconscious into his fall arrest system. A proper risk assessment would have identified the safety procedures required. This was not a causal factor in the incident.

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