Accident investigation of the electrical shock incident at the PG and E PVUSA site Davis, California

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Description

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 ... continued below

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100 p.

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Jacobson, L.; Moskowitz, P.D.; Garrett, J.O. & Tyler, R. February 1, 1992.

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This report is part of the collection entitled: Office of Scientific & Technical Information Technical Reports and was provided by UNT Libraries Government Documents Department to Digital Library, a digital repository hosted by the UNT Libraries. It has been viewed 22 times , with 5 in the last month . More information about this report can be viewed below.

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Description

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.

Physical Description

100 p.

Notes

OSTI as DE96003680

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  • Other Information: PBD: Feb 1992

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  • Other: DE96003680
  • Report No.: BNL--62360
  • Grant Number: AC02-76CH00016
  • DOI: 10.2172/188526 | External Link
  • Office of Scientific & Technical Information Report Number: 188526
  • Archival Resource Key: ark:/67531/metadc670938

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Office of Scientific & Technical Information Technical Reports

Reports, articles and other documents harvested from the Office of Scientific and Technical Information.

Office of Scientific and Technical Information (OSTI) is the Department of Energy (DOE) office that collects, preserves, and disseminates DOE-sponsored research and development (R&D) results that are the outcomes of R&D projects or other funded activities at DOE labs and facilities nationwide and grantees at universities and other institutions.

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Creation Date

  • February 1, 1992

Added to The UNT Digital Library

  • June 29, 2015, 9:42 p.m.

Description Last Updated

  • Nov. 18, 2015, 11:30 a.m.

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Jacobson, L.; Moskowitz, P.D.; Garrett, J.O. & Tyler, R. Accident investigation of the electrical shock incident at the PG and E PVUSA site Davis, California, report, February 1, 1992; Upton, New York. (digital.library.unt.edu/ark:/67531/metadc670938/: accessed October 17, 2017), University of North Texas Libraries, Digital Library, digital.library.unt.edu; crediting UNT Libraries Government Documents Department.