An oriented-strand board manufacturer operated its plant on a24-hour, 7-day work week with two 12-hours shifts. Shift changesoccurred at 8:00 am and 8:00 pm. At approximately 8:30 pm onJanuary 18, 2001, a wet hog, which was located in a wood room,dropped off line and would notoperate.

The wet hog was used to grind tree bark and wood residue into awet fuel used in wet-fuel burners in the plant. The wet hog was notessential to the operation of the plant, and whether or not it wasoperating had no effect on other operations in the plant.

An electrician was assigned to repair the hog. At approximately10:30 pm, he entered the motor control room and opened a 2300-voltmotor circuit breaker. He caused an electrical fault in the circuitbreaker, apparently by contacting energized parts inside thecircuit breaker cubicle, and the ensuing electric arc burned theemployee and ignited his clothing.

He sustained burns over 90 percent of his body, 60 percent ofwhich were third-degree burns. Even thought he was badly burned, hedeparted the motor control center and walked approximately 43meters to the first aid room. A nearby employee doused theremaining flames with water from a watercooler.

Two emergency medical technicians who worked at the plant wentto the first aid room and administered first aid to the injuredemployee. Emergency medical services arrived a few minutes laterand transported the electrician to a hospital where he was admittedfor treatment. The electrician died the next day at 12:11 pm.

What actions could have been implemented to prevent thisfatality?