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California Department of Health Services
A summary
of this document is available in english and spanish.
(Un resumen de este documento está disponible en inglés y español.)
SUMMARY: CASE
292-327-01
Some
greenhouses grow vegetables from seeds. As the plants grow,
they need to be trimmed. A celery cutter came back from his
afternoon break to continue cutting celery plants. The cutting
machine he used looked like a lawn mower. An extension cord
was needed to reach an electrical outlet. The extension cord
he used was missing the third prong. Also, puddles of water
were on the floor from watering the plants. Shortly after
grabbing the cutting machine, he received an electrical shock.
He couldn't let go of the handle. He screamed for help.
A co-worker
ran over and unplugged the cutting machine. The injured worker
fell to the ground, dazed and weak. Their supervisor told
the co-worker to drive the injured worker to a walk-in clinic.
From there he was driven to a hospital, where he was treated
and spent the night.
How
could this injury have been prevented?
- Employers
should make sure work areas are free of hazards (such as
water on the floor).
- Supervisors
and workers should call 911 if someone has an electrical
shock.
- Employers
should use injury prevention programs. These programs can
help employers identify and fix hazards.
- Workers
should wear electrically insulated gloves and boots when
working in wet areas with electric equipment.
BACKGROUND
On August
21, 1992, a nurse from the NURSE Project, while reviewing
records at an acute care general hospital, identified an electrical
shock injury which occurred at a vegetable transplant nursery.
On July 16, 1992, a 23 year-old Hispanic male received an
electrical injury while cutting the tops of celery seedlings
with an electric cutting machine. He had been employed for
3 years at the transplant nursery, and the last 18 months
as a cutter.
The
transplant nursery began operations in 1981. It employs 80
full-time workers (working 38+ weeks per year), 40 seasonal
workers (working 13-37 weeks per year), 20 casual workers
(working 1-12 weeks per year), and 4 family members. The injured
cutting machine operator was a full-time worker. Transplant
nurseries grow seedlings of celery, lettuce and other vegetables
in protected controlled environments called nurseries. They
are grown until ready to be planted by either hand or machine
in a field.
A bilingual
nurse from the NURSE Project interviewed the injured worker
by telephone on September 30, 1992. On November 24, 1992,
another nurse from the NURSE Project discussed the incident
with the current safety director (not the safety director
at the time of the injury), the plant engineer, and maintenance
workers at the nursery, and conducted an on-site investigation.
The nurse learned that the plant had investigated the incident,
but no documentation was available. The NURSE staff also reviewed
the injured worker's medical records.
The
California Occupational Health and Safety Administration (Cal-OSHA)
was not notified and did not investigate this incident.
At the
time of the NURSE investigation, the transplant nursery was
unable to locate their written injury and illness prevention
program, as required by Title 8 California Code of Regulations
3203 -- Injury and Illness Prevention Program. (As of July
1, 1991 the State of California requires all employers to
have a written seven point injury prevention program: 1. designated
safety person responsible for implementing the program; 2.
mode for ensuring employee compliance; 3. hazard communication;
4. hazard evaluation through periodic inspections; 5. injury
investigation procedures; 6. intervention process for correcting
hazards; and 7. provide safety training and instruction.)
The
cutting machine operator said he had received oral safety
training in operating the electric cutting machine from his
supervisor.
INCIDENT
On July
16, 1992, at approximately 4:10 p.m., a cutting machine operator
received an electrical shock while cutting the tops of celery
seedlings inside a transplant nursery. Cutting celery seedlings
is done to keep them at the same height so they receive the
same light exposure. Other cutting machine operators had complained
of receiving electrical shocks from this same cutting machine
in the past.
The
electric cutting machine has a 20-inch rotary cutting blade
similar to a standard electric lawn mower. The cutting machine
is mounted to a large metal frame which holds the machine
above the celery seedlings. This metal frame is secured to
the floor of the nursery building. The cutting machine is
maneuvered by holding the metal frame. It moves on the metal
frame from side to side and front to back, and the height
is adjustable. It is powered by 110 voltage, from a long 3
prong extension cord connected to an electrical outlet. The
extension cord can be plugged into a ground fault circuit
interrupter (GFCI) housed in a five-gallon bucket; or, the
GFCI can be bypassed and the extension cord can be plugged
directly into the growing shed's electrical system. These
five-gallon buckets are stored in a maintenance shed. The
GFCI's are used in wet environments to cut the electrical
circuit if there is a ground fault. Ground faults occur when
the electrical circuit is broken or leaks and the electrical
current travels through the electric machine user to the ground,
instead of through the machine to the ground. 110 voltage
in contact with wet skin can provide a shock powerful enough
to kill someone.
The
ground was wet from the indoor sprinkler irrigation system
when the cutting machine operator returned from his late afternoon
break. He had been using this cutting machine the entire day.
He was wearing tennis shoes and his feet were wet. The third
(or ground) prong on the cutting machine's extension cord
had previously been broken off so that there was no continuous
ground to the cutting machine. The GFCI had been bypassed
and the extension cord was plugged into an electrical socket.
When
approaching the cutting machine, the cutting machine operator
grasped the metal frame to continue cutting the tops of celery.
After taking about 10 steps forward, he suddenly received
an electrical shock. This electrical shock caused his hands
to contract on the handle, and he could not let go. He screamed
for help, and a co-worker (also a cutting machine operator)
who was working about 100 feet from the area heard the scream.
He reached the injured worker within seconds, and unplugged
the cutting machine. The injured worker fell to the ground.
The
injured cutting machine operator was conscious, but dazed
and weak. The same co-worker took him to the lunchroom. He
called their supervisor, who arrived in a few minutes. The
supervisor instructed the co-worker to take the injured machine
operator, by car, to a local walk-in medical clinic which
handles minor injuries. The injured worker arrived at the
clinic at approximately 4:45 p.m., and was seen by a doctor
at 4:52 p.m. He told the doctor that his hands, arms and legs
muscles were cramping. Also, he was experiencing blurred vision.
After examining him, the doctor referred him to a local acute
care general hospital emergency department for further evaluation.
The co-worker placed the injured worker back into his car
and drove him to the local acute care general hospital emergency
department. They arrived at the emergency department at 6:19
p.m. The injured machine operator now said he had chest pain
and was very tired. At 6:30 p.m., an IV was started and blood
was drawn to assess the damage to his heart. The injured worker
was placed on a heart monitor.
The
injured cutting machine operator was admitted to the intensive
care unit for observation, laboratory testing, heart monitoring
and neurological evaluation for subsequent effects of his
electrical shock. After extensive testing, heart damage was
ruled out and the next day, the injured worker was discharged
with instructions to return if his headache, fatigue or general
condition worsened.
At the
time of the interview, one month after the incident, the worker
told the bilingual nurse that he still felt weak from the
injury and was still out of work.
PREVENTION STRATEGIES
- Employers
should ensure that the work environment is free from hazards.
In this incident, the floor of the shed was usually wet
due to the indoor sprinkler system, allowing water to puddle.
In a conversation with the safety engineer, he explained
that after this incident drainage systems had been installed
in all of the nursery buildings to prevent water from pooling.
This injury could have been prevented if the lack of drainage
of water had been identified as a potential hazard.
- In
the past workers had received electrical shocks from using
this cutting machine. At the time of the incident, the nursery
could not locate their written injury and illness prevention
program. On February 4, 1993, however, the nurse from the
NURSE Project revisited the nursery and was able to review
their written injury and illness prevention program with
the safety director. It did address all seven points as
required by Title 8 California Code of Regulations 3203
(Title 8 California Code of Regulations 3023: Illness and
Injury Prevention Program). Nonetheless, if the employer
had an intervention process for correcting hazards, and
had corrected this hazard of workers receiving electrical
shocks, this injury may have been prevented.
- Employers
should train workers to inspect equipment before beginning
their work tasks. In this incident, the extension cord used
between the cutting machine and the electrical power source
was missing its ground prong (it had been broken off). If
the injured cutting machine operator had been trained to
care for and inspect the equipment being used, he may have
realized that the extension cord needed to be replaced,
and the injury may have been prevented. Also, in this incident,
if periodic monitoring of the cutting machine and frame
was conducted to test for electrical grounding deficits,
this injury might have been prevented. After the incident,
the employer began monitoring all of the cutting machines.
- Employers
should have an appropriate emergency response plan (Title
8 California Code of Regulations 3400(b): "In the absence
of an infirmary, clinic, or hospital, in or near proximity
to the workplace... a person or persons shall be adequately
trained to render first aid." Title 8 California Code of
Regulations 3439(b): "There shall be at least 1 employee
for every 2 employees at any remote locations with training
for the administering of first aid.") This includes having
supervisors trained in first aid and cardiopulmonary resuscitation
(CPR) and workers trained to call 911 when someone is injured.
In this incident, the supervisor instructed the co-worker
to take the injured machine operator to a medical clinic.
If the supervisor had been trained in first aid and CPR,
he would have known to call 911 and allow paramedics to
transport the injured worker to a hospital emergency department.
- Employers
should consider safety when building or modifying equipment.
In this incident, the frame of the cutting machine should
have been equipped with an electrically insulated plastic
handle for the cutting machine operator to hold and guide
the cutting machine. If the cutting machine had been equipped
with a plastic handle, the worker would have been protected
from electrical shock because plastic will not conduct low
voltage (110 volts) electricity. In addition, the ground
fault circuit interrupters (GFCI) should be installed as
part of the electrical system for the nursery, instead of
being in mobile five-gallon buckets.
- Employers
should have written standard operating procedures. In this
incident, the standard operating procedure for using GFCI
buckets was unwritten, and not enforced. The GFCI buckets
were supposed to be picked up from a maintenance shed and
taken to the nursery. In this incident, although the worker
may have received some training, clearly he did not understand
the importance of using the GFCI. If he did understand,
he might not have bypassed it. Also, if this standard operating
procedure had been enforced, the injured cutting machine
operator would not have been able to bypass the GFCI.
- Workers
should be provided with and required to use personal protective
equipment. When working with energized equipment in a wet
environment, workers should wear electrically insulated
gloves and boots. In this incident, if the worker had been
wearing insulated gloves and boots, the electrical current
may not have established a path to ground through his body
and he may not have received an electrical shock.
FURTHER INFORMATION
For further
information concerning this incident or other agriculture-related
injuries, please contact:
NURSE
Project
California Occupational Health Program
Berkeley office:
2151 Berkeley Way, Annex 11
Berkeley, California 94704
(510) 849-5150
Fresno
office:
1111 Fulton Mall, Suite 212
Fresno, California 93721
(209) 233-1267
Salinas office:
1000 South Main St., Suite 306
Salinas, California 93901
(408) 757-2892
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Disclaimer
and Reproduction Information: Information in NASD does not
represent NIOSH policy. Information included in NASD appears
by permission of the author and/or copyright holder. More
NASD Review: 04/2002
This
document,
CDHS(COHP)-FI-93-005-28
, was extracted from a series of the Nurses Using Rural Sentinal
Events (NURSE) project, conducted by the California Occupational
Health Program of the California Department of Health Services,
in conjunction with the National Institute for Occupational
Safety and Health. Publication date: March 1993.
The
NURSE (Nurses Using Rural Sentinel Events) project is conducted
by the California Occupational Health Program of the California
Department of Health Services, in conjunction with the National
Institute for Occupational Safety and Health. The program's
goal is to prevent occupational injuries associated with agriculture.
Injuries are reported by hospitals, emergency medical services,
clinics, medical examiners, and coroners. Selected cases are
followed up by conducting interviews of injured workers, co-workers,
employers, and others involved in the incident. An on-site
safety investigation is also conducted. These investigations
provide detailed information on the worker, the work environment,
and the potential risk factors resulting in the injury. Each
investigation concludes with specific recommendations designed
to prevent injuries, for the use of employers, workers, and
others concerned about health and safety in agriculture.
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