Situation: An oriented-strand board manufacturer operated its plant on a 24-hour, 7-day work week with two 12-hours shifts. Shift changes occurred at 8:00 am and 8:00 pm. At approximately 8:30 pm on January 18, 2001, a wet hog, which was located in a wood room, dropped off line and would not operate. The wet hog was used to grind tree bark and wood residue into a wet fuel used in wet-fuel burners in the plant. The wet hog was not essential to the operation of the plant, and whether or not it was operating had no effect on other operations in the plant. An electrician was assigned to repair the hog. At approximately 10:30 pm, he entered the motor control room and opened a 2300-volt motor circuit breaker. He caused an electrical fault in the circuit breaker, apparently by contacting energized parts inside the circuit breaker cubicle, and the ensuing electric arc burned the employee and ignited his clothing. He sustained burns over 90 percent of his body, 60 percent of which were third-degree burns. Even thought he was badly burned, he departed the motor control center and walked approximately 43 meters to the first aid room. A nearby employee doused the remaining flames with water from a water cooler. Two emergency medical technicians who worked at the plant went to the first aid room and administered first aid to the injured employee. Emergency medical services arrived a few minutes later and transported the electrician to a hospital where he was admitted for treatment. The electrician died the next day at 12:11 pm. Make a root cause analysis and What actions could have been implemented to prevent this fatality?

Situation: An oriented-strand board manufacturer operated its plant on a 24-hour, 7-day work week with two 12-hours shifts. Shift changes occurred at 8:00 am and 8:00 pm. At approximately 8:30 pm on January 18, 2001, a wet hog, which was located in a wood room, dropped off line and would not operate. The wet hog was used to grind tree bark and wood residue into a wet fuel used in wet-fuel burners in the plant. The wet hog was not essential to the operation of the plant, and whether or not it was operating had no effect on other operations in the plant. An electrician was assigned to repair the hog. At approximately 10:30 pm, he entered the motor control room and opened a 2300-volt motor circuit breaker. He caused an electrical fault in the circuit breaker, apparently by contacting energized parts inside the circuit breaker cubicle, and the ensuing electric arc burned the employee and ignited his clothing. He sustained burns over 90 percent of his body, 60 percent of which were third-degree burns. Even thought he was badly burned, he departed the motor control center and walked approximately 43 meters to the first aid room. A nearby employee doused the remaining flames with water from a water cooler. Two emergency medical technicians who worked at the plant went to the first aid room and administered first aid to the injured employee. Emergency medical services arrived a few minutes later and transported the electrician to a hospital where he was admitted for treatment. The electrician died the next day at 12:11 pm. Make a root cause analysis and What actions could have been implemented to prevent this fatality?