Accident investigation of the electrical shock incident at the PG and E PVUSA site Davis, California
This report summarizes the findings of the Accident Investigation Team (Team) assembled in response to a request from Pacific Gas and Electric Company (PG and E) to the US Department of Energy (DOE) to understand the events surrounding the electric shock of a worker at the PVUSA site in Davis, California and to provide recommendations to prevent such events from recurring. The report gives complete details on the sequence of events surrounding the accident and identifies 27 facts related to accident itself. Four technical deficiencies in the electrical systems which require further investigation were identified. The Team believes that the root cause of this accident was related to the absence of a proactive organizational entity responsible for overall health and safety on the site. Two contributing factors were identified. First, the prototype nature and associated operational difficulties of the electrical inverter resulted in large maintenance demands. Second, several of the injured employee`s co-workers noted that he occasionally failed to use appropriate personal protective equipment, but they never reported this practice to management. The direct cause of this accident was the failure of the injured employee to wear appropriate personal protective equipment (i.e., rubber gloves). Based on the review of the facts established in this investigation, five recommendations are presented to the funding agencies to reduce the possibility of future accidents at the PVUSA site.
- Research Organization:
- Brookhaven National Lab. (BNL), Upton, NY (United States)
- Sponsoring Organization:
- USDOE, Washington, DC (United States)
- DOE Contract Number:
- AC02-76CH00016
- OSTI ID:
- 188526
- Report Number(s):
- BNL-62360; ON: DE96003680; TRN: AHC29604%%2
- Resource Relation:
- Other Information: PBD: Feb 1992
- Country of Publication:
- United States
- Language:
- English
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