Date of incident: January 2024
Notice of incident number: 2024181430009
Employer: Pulp mill

Incident summary
A worker at a pulp mill was using a pendant control to operate an overhead hoist while leaning over a metal railing. The railing became energized, and the worker received an electric shock from it. He was transported to hospital by ambulance and later died from his injuries.

Investigation conclusions

Cause

• Exposed conductor from damaged cable energized metal railing. At some time prior to the incident, the hoist’s power cable likely contacted a sharp object. The sharp object caused surface damage to the power cable and exposed a conductor, which contacted the railing and energized it.

Contributing factors

• Inadequate pre-use inspection procedure. The employer’s pre-use inspection procedure for the hoist was inadequate because it did not specify that the power cable should be inspected. Had the power cable been inspected on the day of the incident, it is likely that the exposed conductor would have been identified, and the hoist subsequently de-energized and taken out of service.
• Lapsed annual certification. When the incident occurred, the annual inspection and certification of the hoist was overdue. The annual inspection includes an examination of the hoist’s power cable, and the damage to the power cable likely would have been detected during the annual inspection.
• Inadequate power cable handling. The hoist’s power cable was flexible, and it was typically draped over equipment, or it rested on the floor with no protection. The hoist should have been equipped with a take-up device to take up the power cable slack and thereby prevent the risk of damage that can occur when slack cable comes into contact with other equipment or sharp objects.

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