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### Inspection Detail

**Case Status: CLOSED**

#### **Inspection: 1566326.015 - Uss-Upi, Llc**

**Inspection Information - Office: Ca American Canyon District Office**

 

**Inspection Nr**

**Report ID**

**Date Opened**

----

**Site Address**: 			   Uss-Upi, Llc			   900 Loveridge Rd.Pittsburg, CA 94565

**Mailing Address**: 			   Po Box 471, Pittsburg, CA 94565

**Union Status**: Union

**SIC**:

**NAICS**: 332313/Plate Work Manufacturing

----

**Inspection Type**: Fat/Cat

**Scope**: Partial

**Advanced Notice**: N

**Ownership**: Private

**Safety/Health**: Safety

**Close Conference**: 05/02/2022

**Emphasis**:

**Case Closed**: 03/25/2024

----

**Case Status: CLOSED**

#### **Investigation Summary**

**Investigation Nr**

**Event**

At 11:15 a.m. on November 26, 2021, Employee #1 was repairing a Power Corp Type PIF Load Break Interrupter Switch (employer's designation: disconnect switch 103 in 13.8kV Switchgear #1) located in the 13.8kV Switchgear Room that serves Stand 5 of the Pickle Line Tandem Cold Mill (PLTCM).  A problem with disconnect switch 103 was reported when it was closed on November 21, 2021 to provide power to Stand 5 of the PLTCM during start up preparations for the week's production run. A metallic noise, indicating loose parts inside the switch, was heard by the electrician who closed the switch. An entry was made in the computer log of the PLTCM, documenting the mechanical issue, and Employee #1, the Field Service Electrical and Crane Crew Supervisor - Reliability Division, was notified.   At 11:15am on November 26, 2021, the smoke alarm actuated in the PLTCM area and the employer's on-site emergency personnel responded to investigate. Upon entering the 13.8kV Switchgear Room, they observed smoke in the room and found Employee #1 on the floor in front of Section 103 of 13.8kV Switchgear #1. His clothing was on fire, and he was suffering from burns and other trauma resulting from an arc flash inside the switchgear cubical.  Employee #1 had apparently reached into the enclosure and contacted the live line-side terminals of the switch resulting in an arc flash that resulted in burns and other trauma. He died on November 29, 2021.  Employee #1 was not wearing the proper PPE for work on live electrical equipment. Employee#1 was working alone, without an observer or standby person present. The required steps for deenergizing and grounding the equipment for employee protection, when working in high voltage equipment, had

**Keywords:**burn, circuit breaker, electric arc, electric arc flash, electric switch, equipment grounding, high voltage, lockout, lockout/tagout, machine guarding, protective clothing, protective grounding, work rules
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