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Utility Electric Power Challenges Related to a Level 3 Trauma
Hospital’s Electrical Vault Failure, its Recovery Operations, Regulatory
Challenges and the Evolving Challenges of Temporary Generation
OR
The Hospital, the Utility, the Explosion and the Aftermath
Mike Moore
Walker Engineering
1505 W. Walnut Hill Lane
Irving, Texas 75038
USA
mmoore@walkertx.com
Abstract - This case study will be a chronicle of events
that were encountered through on site interactions with
qualified electrical workers, executives, corporate managers,
and safety professionals while interacting with a large
nationally recognized medical management corporation and
one of its hospital locations in the Dallas, Texas Area. The
medical facility experienced a complete electrical failure
promulgated by the actions of an unqualified electrical worker
that resulted in an arc flash/blast incident in one of four
hospital electrical utility vaults. The event severely burned an
experienced electrical worker, an experienced utility worker,
a hospital maintenance director as well as a general
maintenance worker. The goal of this presentation is to
communicate the specific details, accounts and challenges
that allowed the incident to occur and the human failures,
poor safety related work practices and cultures that were
exhibited during this project. These poor safety related work
practices and cultures seem to plague many industrial
facilities, utilities and large commercial enterprises even to
this very day even though the ability to calculate and identify
electrical hazards, communicate them, mitigate them and
protect the electrical worker are easier to manage today than
ever before. There were several key strategies employed by
the disaster recovery personnel to counter the site hazards that
included dealing with exposed energized conductors, poor
electrical equipment grounding, inclement weather, human
limitations, limited qualified recovery personnel, site inner
and inter-company politics, as well as the disaster sites
management’s limited knowledge about electrical safety, their
electrical system, disaster preparedness and limitations of
liability when it comes to forcing contractors to work in a
hazardous condition.
I. WEEKEND FIRE INJURES THREE WORKERS AT A
LOCAL HOSPITAL
From: The News Headlines on May 4th
, 2010
An accidental weekend explosion at a local hospital burned
three hospital workers and caused $300,000 in damage to an
outbuilding. The local firefighters arrived at the hospital
shortly after 2 p.m. Sunday and quickly extinguished the fire
in a one-story structure near the hospital's loading docks, the
Fire-Rescue spokesman said in a news release today.
Witnesses said the explosion was sparked by an electrical
short created when a contractor attempted to transfer power,
the spokesman said. Three men were injured in the explosion,
he said. Two victims were taken to a burn unit at a local
hospital by air ambulance, and the third was treated at the
hospital where the event occurred. The extent of their injuries
is unknown.
II. THE BLAST
A. Events Leading Up to the blast
On May 2nd, 2010 just after midnight an electrical testing
contractor had completed the replacement of a 4000 Amp fused
low-voltage bolted pressure switch on side “A” of the hospital’s
switchgear being fed from the West Vault of the local utility.
Once completed the electrical testing contractor’s technicians
communicated to their customer (the hospital) that the site was
clear of their personnel, that all safety grounds and locks had
been removed from the equipment in the facility and that the
hospital was clear to discuss energizing the site with the utility.
The electrical testing contractor’s personnel withdrew from the
power building to the parking lot adjacent to the main utility
vault and switchgear room. The utility worker entered the vault to
begin the process of energizing the incoming 15 kV switch while
close behind him were three other workers or hospital staff

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members observing the utility worker. Two of these hospital
workers entered the vault while the third waited just outside the
door. Moments later a loud explosion occurred and the entire site
went dark.
B. The Rest of the Story
The utility worker involved tried to energize the vaults
main 15 kV oil filled circuit breaker several times. This is
typically performed remotely through a network of
communications and controls. The circuit breaker would “trip
free” and reset to the charged position. After several failed
attempts to close the circuit breaker the utility worker noticed
that an over-current relay was flagged and what was blocking
the circuit breaker from closing. The utility worker removed
the sliding disconnect paddle from beneath the protective
relay, isolating it from the trip circuit. The utility worker tried
to operate the circuit breaker one more time manually. The
results were catastrophic. All 4 workers in the vault were
medically evacuated via helicopter to another local trauma
center that was equipped to deal with electrical burn injuries.
The hospital’s emergency generators did not all come on line
due to some transfer switching issues, but eventually with the
testing contractor’s support the “Life and Safety” power was
restored to a limited capacity as well as some power was
restored to the critical facilities on the hospital campus. One
of the workers was treated and released quickly after the
events. This worker became the contact for all disaster
operations at the hospital.
After the smoke cleared the carnage was indescribable. The
oil filled circuit breaker had exploded covering the room in
burning mineral oil from the 15kV switch. The overhead 480
VAC distribution bus and thermal plastic insulators were
covered in burned mineral oil, soot and soda. The fire
extinguishers used to put out the fire had left a nasty mess that
would later be a challenge to contend with. The utility worker
suffered at least a 60% body burns of 2nd
and 3rd
degree. Both
of the unauthorized and unqualified hospital workers who just
happened to be in the utility vault at the same time suffered
2nd
and 3rd
degree burns as well. The two hospital workers
were administrators and maintenance management personnel
nowhere even qualified to be where they were. The third
worker who was standing in the doorway to the utility vault
was the campus maintenance superintendent and only
received small areas of first and second degree burns. None
of the utility or hospital workers were wearing any arc-rated
PPE. The utility worker was wearing a standard issue FR only
rated clothing, a hardhat and safety glasses. The hospital
workers were wearing poly-blend business casual clothing, no
safety glasses or hard hats. It has never been communicated to
the hospital or to the electrical testing contractor why the oil
circuit breaker failed. Even to this day the discussion of the
events is evasive and a point to “not to be discussed”.
The next several days had to be extremely challenging for
the utility company. One of their own long time workers as
well as two hospital workers were now in a regional burn
center with little or no way of communicating what had
happened and what factors lead up to the incident. The utility
was on an information lock down about the events of the
incident and were not delivering any commitments, at all to
anyone, even to the hospital about recovering their electrical
system. The entire site was at a virtual standstill and nobody
seemed to have a direction of what needed to happen next or
maybe they did!
As the next day progressed a frenzy of utility construction
personnel mobilized to the site to repair the damage to the
utility vault and its equipment. The utility’s electrical testing
personnel were testing the transformers, medium voltage
power cables, the low voltage riser cables and overhead bus
work to determine their serviceability. The utility construction
personnel replaced the charred remains of the oil circuit
breaker with a new vacuum circuit breaker. All control
indication and station metering wiring harnesses between the
West & East vaults was replaced, as well as heavy cleaning
and painting of the balance of the electrical equipment. The
damaged utility equipment that left the hospital site did so
covered with tarps cloaked with a thick veil of secrecy. See
figure 1 - 3
Figure 2 – New utility vacuum switch, control transformer,
control cabling and riser cables in the vault

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Figure 2 – Outside view of the melted utility vault
ventilation system that was damaged from the arc blast.
Figure 3 – New fan installed on the utility vault ventilation
system & new medium voltage conductors that feed from
“Vault B”.
By the end of the first day the utility had completely
replaced all of the damaged electrical equipment, tested the
balance of the questionable electrical equipment and made
ready the site to be energized, as long as you didn’t need in
the vault. A simple piece of caution or barrier tape that
crossed what was left of the two doors leading into the vault.
The communication to the hospital was limited to phone calls
only to communicate that they “could repair their bus
whenever they wanted to”. In short; the utility poorly
communicated to the hospital what they were allowed to do or
how to interact or tie into the utilities equipment and chose
never to come to the site and work with the hospital staff.
The testing contractor took the initiative and acted as the
catalyst to begin the communication process between the
temporary power contractor, the hospital and the utility.
Repair, restoration and communication were finally moving
forward.
III. The Hospital Electrical Recovery Project
The electrical testing contractor that had been on site since
the initial disaster event immediately started assisting the
hospital to place the site in an “electrically safe condition”.
That meant locking out all of the four (4) the incoming 4000
Amp bolted pressure switches fed from the “A Vault” that
were associated with the failure, and limiting access into the
hospitals power house and the electric utilities vault notifying
local authorities that the site was on temporary power and that
no utility service existed.
Media arrived on the site looking for comment. They
were lost on who to talk too or where to go. The testing
contractor asked that they come at another day in time when
the proper hospital and utility staff were present to address
their needs and questions.
As the first day drew to a close, temporary power assets
arrived on the site and safety controls were set into place
many local electrical contractors came to the site for a piece
of the action. Some of the electrical contractors wanted the
opportunity to make a quick buck and could care less about
the sensitive nature of the situation. The hospital had already
chosen its support team immediately after the event. That
team consisted of an electrical testing contractor and an
electrical construction contractor. The utility had yet to
include itself into restoring power to the hospital.
A. Temporary Power
The hospital allowed the testing contractor top start
working with their nationally contracted emergency rental
generation equipment provider. The rental electric equipment
supplier and the testing contractor worked nearly 30 hours
straight to get the hospitals electrical system up to some
reasonable level of reliability, but the hospital wanted more
assurances that there would be no more unplanned outages.
The rental equipment supplier had originally positioned 3
MW of generation in the first days after the disaster, but as
the reliability requirements of the hospital grew as did the
capacity of temporary generation which eventually to 6 MW
on-line with an additional reserve of capacity of 3 MW of
generation fueled, cabled in and ready to go when needed.
This configuration offered the hospital redundancy and back-
up if one of the other generators failed. See figures 4 - 6

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Figure 4 – “Switch B” that was fed from the utility “Vault A”
via bus duct, this switch was back-fed from a rental generator
Figure 5 – Day 1 generator set-up with 3 MW of generation.
Figure 6 – Day two with 3 MW of generation capacity on line
and an additional 2 MW of stand-by generation.
If needed, the hospital now had the ability to transition to
the spare generators, but it would take some time and
additional outages to tie in the complex network of generator
cables into the main wiring harness. Additionally all these
generators had maintenance requirements that required
downtime and short start time windows that would cause
small outages. The thought of these potentially outages and
delays were unacceptable to the hospital. Several forced
outages occurred on the second and third days of the project
due to switching, routing fueling and filter changes, but the
hospital refused to allow or accept these challenges and
constantly complained that we were impacting business as we
added reliability; meaning that surgeries and procedures were
delayed and interrupted during the generation events. No
matter how hard we tried to convince them how vulnerable
they were and the challenges we had; it was business as usual
for the hospital.
Additional switching equipment and generators were
located, installed at the site to limit outages related to
maintenance routines and enhance future reliability related tie
in’s, but two more outages would be required for a final tie in
to limit any additional outages See figure 7.
Figure 7 - Day 1 cable harness that fed switchgear. This
system grew more complex as the project went on.
The operation and maintenance of these generators were
extremely critical to the reliability of the site. The back-up
generator’s ability to start and energize the emergency circuits
was even more critical. The failure of any one of the three
generator systems placed in service would leave portions of
the hospital in the dark or could possibly create a life
threatening scenario in the critical care unit of the hospital.
The generators had two critical maintenance routines
that could not be missed or deferred. The routines involved
fuel and air filtration and if any of the two routines were
missed, it would actually force the generators into a shutdown

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mode. The need to perform these maintenance routines were
discussed with the hospital on several occasions. The hospital
administration refused to entertain the idea of taking short
outages to perform these services. Even with a back-up plan
to shed load from the generator to be maintained and to
change its status through an open transition scheme to an
additional stand-by generator, the hospital still refused to
allow the mandatory maintenance process stating “that it was
too risky” and that they “cannot take another outage no matter
how small or short it was”. Therefore the only way these
filters could be changed was during unplanned outages
basically allowing the generator to enter a self-shutdown
mode. These unplanned and unscripted outages happened
routinely every day and created chaos for the hospital and a
few yelling incidents by the staff of the hospital to the
contractors recovering the site. Other than filtration outages,
these generators ran 100% event free for nearly 3000 hours
and consumed close to 35,000 gallons of diesel fuel.
B. Electrically safe
The first order of business with any electrical project is to
secure a copy of an engineered one line diagram of the
existing electrical system. This is even more important when
dealing with a failed electrical distribution system that has
injured workers, has created the possibility of litigation and
will mostly likely create a reason for an OSHA compliance
officer to investigate the site. There was a need for a complete
site one line drawing to accurately size loads and calculate the
power requirements for each building In this instance, an
accurate one line of the site was never found, only small
pieces of various expansions that had happened over the
years. The lack of the one line drawing created a need for a
detailed site temporary power plan and a method to
communicate the changes to the system as they were made.
This temporary power plan would let the hospital and other
contractors know exactly where the temporary power
resources were located and tied in. As the project progressed,
miles and miles and miles of temporary power cables were
strewn across multiple buildings, across parking lots, through
tunnels, through hallways and even through windows and up
the sides of several buildings on the campus. This created
some potentially hazardous situations where hospital
personnel and contractors would have had to walk on the
energized 480VAC cables. One solution was to build
temporary ramps and elevated walkways on top and across
the cables. See figure 8 & 9
Figure 8 – Ramp built over the generator cables going into
the main switchgear room.
Figure 9 – Ramps built over the generator cables to allow for
emergency vehicle access.
The electrical systems bonding and grounding was a
nightmare. Years and years of unqualified and inexperience
electricians had left panel bonding jumpers in place creating
downstream bonding. This installation issue created havoc
with the ground fault relays on the temporary breakers and
generator main circuit breakers. The introduction of the
generator grounds to the facilities grounding system created
large amounts of circulating ground currents system wide.
These circulating currents heated bonding jumpers to high
temperatures causing the connections to smoke, isolated
grounding panels to trip and to eventually fail. Several runs of
the facilities cables failed in large manholes that were filled
with 12 feet of water from recent rains. Cable failures on top
of grounding issues with the added pressure for uptime by the
hospital was becoming a challenge. After two days of
troubleshooting, intersecting cables and isolation of other
cables at various points in the campus electrical system the
grounding problems were somewhat temporarily resolved.
By the time the temporary power scheme was completed
on the third day the entire hospital was now isolated from the
electric utility provider and operating 100% on rental
temporary power generation with a double ended closed

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transition system for redundancy. The hospital; still moved
forward with a business as usual mindset with no regard to the
limitations that had been placed on the electrical
infrastructure, missing support personnel and the fact that
there was no guarantee that the utility would allow anyone to
repair the service entrance anytime soon. Day three was soon
to come as nightfall went away and the sun rose in the
gorgeous Texas Spring sky.
C. The Service Entrance
Since the electrical testing contractor was already on-site
and contracted to support switchgear repair, the hospital
maintenance staff asked them to evaluate the feasibility of
rebuilding all four service entrance transition pieces from the
utility vault that went into each hospital power room. Access
to work on the customer owned equipment inside the utility
owned vault had its own challenges. Early discussions with
key management of the utility company, the hospital and the
electrical testing contractor yielded a small four-day window
for the electrical testing contractor to remove the three
customer-owned service entrance transition pieces from the
utility vault, rebuild them, set them in place and reconnect
them into the utility’s distribution system.
Day (3) three started out as a major challenge. The utility
had not communicated its plan to allow contractors into the
vault to its own workers. Several vice presidents, managers
and utility workers arrived at the site to evaluate the damage
and the repairs to the vault. These workers would “run us out”
of their vault and tell us not to re-enter. There were multiple
times where we had to demobilize due to poor utility
communications. Additional generator related outages,
rainstorms, hailstorms and hospital meetings created
leadership challenges for the very small qualified crew to
perform very niche work in a very critical and extremely
dangerous work environment. At this point at least once an
hour to every two hours a challenge occurred that impacted
and slowed the recovery processes and at times stopped all
work. The initial communication to the testing contractor was
that the transition sections were remain in place as is. The
utility company communicated that since the service was only
480 VAC equipment that “just blowing them out would
suffice”. Additional educational discussions concerning long
term reliability on behalf of the hospital persuaded the
hospital management company’s executives to pressure the
electric utility to allow the complete removal and repair of all
of the transition sections. The recovery tasks of the
customer’s cables and bus duct associated with each transition
piece was even more of a challenge than originally planned.
Two of these transition pieces were connected to 3000 A bus
duct, the third was connected to forty (40) 500MCM THHN
cables. The three service entrance transition pieces from the
utility vault were severely burned and required complete
disassembly and cleaning, re-plating and reinsulating. See
figures 10 through 12
Figure 10 – Transition section “Feeder C” and “Feeder F”
equipment after the arc blast and covered with soda from the
fire extinguishers. “Feeder C” is the transition section fed by
cables on top of “Feeder F”.
Figure 11 – Bus duct “Feeder D” transition after the arc blast
and covered with soda from the fire extinguishers
Figure 12 – Bus duct “Feeder F” transition after the removal
from the vault. Note the ingress of soot and soda.

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OSHA made their appearance to the disaster site on the
third day as they would with any incident that injures three or
more workers. The OSHA compliance officer had a very
professional approach to their line of questioning. The OSHA
representative evaluated the overall site for any existing
hazards, thoroughly questioning the testing contractors about
their knowledge of the events about the prior days and the
evening of the blast, the current condition of the electrical
distribution system, the damaged electrical equipment, the
temporary power installation contractor and qualifications,
the plans for the recovery of the hospitals electrical system
and if there were any safety challenges that were being
experienced on site. The electric utility had no representation
at the disaster site during OSHA’s review, the utility vault
was open, unsecure and exposed to the public. The hospital
staff did not seem to understand the gravity of the situation
and could not properly answer the questions being asked of
them by the OSHA compliance officer. The OSHA
compliance officer left after just less than an hour on the site
and with more questions than answers. OHSA documented
the events on their enforcement site. See figure 13
Figure 13 – OSHA documented case of the injuries of 4
workers, not three as reported by the news and other sources.
In addition to the concerns about the removal of the bus
duct connectors the utility refused to allow any of the site
contractors to clean any of the 480 VAC complex weave of
overhead station bus work, stand-off insulators, bracing and
barriers that supported the hospital. To this day it has never
been cleaned or maintained. To this day the utility accepted
Insulation Resistance readings that were left in electric
service at 30K Ohms, ANSI/NETA MTS states that it should
be 100M Ohms at a minimum. See figure 15
Figure 15 – The utility vault’s 480 VAC bus work that
remains in service to this day and still charred and covered
with soda from the fire extinguishers. Bus duct “Feeder D” is
far left, “Feeder C” & “Feeder F” are located to the far right
and mounted one on top of another.
The transitions sections required 6 electricians working
about six to eight hours each to remove from the utility vault.
Once these were removed from the site they were transported
to the electrical testing contractor’s electrical repair facility
for a complete disassembly, cleaning and remanufacture to
“like new”. All copper energized parts were bead blasted to
bare copper and polished. All connections were re-plated with
6 MILS of tungsten silver plating, all insulating boards,
barriers and stand-off bushings were replaced, all exterior
metal and bracing were sand blasted and powder coated with
ANSI 61 Grey epoxy paint, and all hardware was replaced.
Mylar insulating tapes and sheets replaced the factory
fluidized epoxy bus coating. After an around the clock
process the components were re-assembled, electrically tested
and ready for delivery in two-and–a-half days. See figures 14
through 17.

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Figure 14 – Completely remanufactured bus transition section
that fed bus duct “Feeder D”
Figure 16 - Completely remanufactured bus transition section
that fed bus duct Bus duct “Feeder F”
Figure 17 – Completely remanufactured “Feeder C” bus
section.
The two 3000 Amp bus ducts sustained heavy smoke and
blast damage. The soot and soda material from the fire
extinguishers used to put out the fire and the extinguishers
high pressure nozzle pushed contaminates well inside two of
the ten foot sections of the bus duct on “Feeder D” & “Feeder
F”. The conduits for “Feeder C” sustained heavy soot and
soda contamination as well. There were signs of cable
insulation failure and shorting of conductors at the entrance to
the conduits. See figure 18 & 19.
Figure 18 – Transition section “Feeder C” and “Feeder F”
equipment as seen from the hospital equipment room after the
arc blast. Evidence of the blast is visible, note soot on the
sides of the bus duct, and the arcing on the lower left corner
of the transition box for “Feeder C”
Though this was only 480VAC equipment, the dissimilar
compounds at the connections combined with moisture had
already created the beginning of an acidic process that turned
the silver plating black and started the “whiskering” process.
The copper had turned from a dark brown and was slowly
turning to a bright green as well. Soot from the blast was
found 80ft to 100ft feet away in opposing conduits not even
related to the blast.
Figure 19 – Transition section “Feeder D” equipment as seen
from the hospital equipment room after the arc blast.
Evidence of the blast is visible, note soot on the sides of the
bus duct.
Four each of the ten foot sections of the hospitals bus duct
for “Feeder D” & “Feeder F” had to be disassembled and
cleaned while on site. Soot traveled inside both sections of

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bus duct on each feeder. The bus duct compression plates
were buffed to bare copper and polished with the connection
points being re-plated in the field with 2 to 3MILS of
tungsten silver. The insulating plates were cleaned with
denatured alcohol and were determined to be suitable for
continued service.
The third and fourth service entrances “Feeder C”
connected forty 500MCM conductors to an older installation
in the hospital equipment room and presented the greatest
repair challenge. How do you replace eighty conductors that
are still connected to the rear of a section of the switchgear
directly above the energized common bus when power
outages are forbidden? The hospitals answer to all involved
was; “you do it energized” or at least that was the hospital’s
original intention.
D. “Doing it Energized”
The hospital had repeatedly requested and directed that
“there are to be no more outages taken for any reason
whatsoever”. This requirement was repeated in each and
every operations and safety meeting the contractors had with
the hospital staff. The electrical testing contractor and its
electrical contractors did not relish the idea of a demolition of
conductor’s job energized. Cutting away and removing cables
directly above energized 3000 Amp and 4000 Amp common
switchgear buses. Performing this task while the bus was
energized was extremely risky and of the highest hazard, but
someone had to convince the hospital that it was not in their
best interest to risk anyone else’s life to perform an unsafe
task especially since OSHA had just left the site and three
workers were still fighting for their life in the hospital. Even
though it was communicated verbally that “You can’t ask
someone to perform an unsafe task, much less make them for
monetary reasons”, they still refused to submit.
The electrical testing contractor’s plan was to develop an
energized work strategy for two reasons;
1) To acknowledge the risk and the hazards to the
hospital, to place that burden of risk on them and to remove it
from the electrical testing contractor; it’s their electrical
hazard, they should assume the risk
2) To develop a plan to perform the task if they
were forced to execute the tasks while the equipment was
energized.
The plan had several key steps.
Step 1 was to identify the hazards.
The shock hazard was 480 VAC fed through
temporary cables directly from the output terminals of an
insulated case circuit breaker from a 2 MW generator. The
case was made to protect the workers from a possibility of
shock by isolating the energized bus by securing voltage rated
blankets in place with clips and tapes manufactured
specifically for the operation and task. The arc flash/blast
hazard was calculated at 38 cal/cm2
. Though below 40
cal/cm2
it was considered high enough to bring into question
the reliability of the unmaintained generator main circuit
breaker, the maintenance cycle of the breaker and any
established performance data from the maintenance program.
No maintenance data existed and there was no knowledge of
when the last tests were performed on that breaker.
Additionally, performing the cutting and removal of cables
while wearing arc rated clothing introduced additional
concerns, especially with the wearing of Class 0 gloves and
the need for fine motor skills to turn Allen head bolts, all
while positioned above energized bus.
Step 2 was to identify the most qualified and experienced
electrical installers.
The electrical contractor had some extremely
qualified personnel, but did not have the skill sets needed to
perform the high hazard task. The site manager and safety
manger selected key experienced and trusted personnel. They
asked and documented a barrage of questions of each
electrical worker about the company safety practices,
company safety policy, electrical theory, their individual
families, arc flash knowledge as well as key points about the
task at hand as they understood it. The worker selection
process identified the most qualified workers for the task.
Step 3 was to develop a written procedure.
There had to be a written procedure for limiting non-
essential and un-qualified personnel egress into the building.
This included hospital personnel, generator support
personnel, utility personnel, and even the contractor’s support
personnel. There was also a procedure developed to install
insulating blankets over the common bus with specific
mounting locations of the hardware to be used to secure it.
The most in-depth procedure was the cutting and extraction of
the cables from the top side of the main switch located just
above the common bus. The procedure detailed what to cut,
how to cut it, the number of personnel involved in the task
and their position relative to the equipment they are working
on.
Step 4 was to notify the personnel.
The contractor’s energized safe work plan required that all
parties be notified prior to the performance of an energized
task. This included their senior management & ownership, the
electrical testing contractor’s management and the hospitals
staff and management. The most personal or key part of the
plan was to notify the family of the selected workers about the
risk they were taking on in behalf of the hospital and offer
them a voice in the matter. This required the contractor’s
manager to call and discuss the plan with the spouse or
family, as well as the worker communicating his willingness
to participate verbally to his spouse.

10. Revision 3, 2016 10
Step 5 was to develop an emergency response plan
The development of a disaster response plan was critical
in performing a task such as this. If medical attention was
needed, the hospital would most likely not be able to support
it, as their power would be out. The plan included emergency
first responders already on site, the identification and
notification of a trauma center, a “first call” plan, as well as a
plan on what to do to get the site restored if the worst were to
happen.
Step 6 the final step.
This highly elaborate step specifically required that the
workers, the workers supervisors and the electrical testing
contractor management all understood the task, its hazards
and the gregarious amount of risk involved. The plan
required the hospital management to sign a document
accepting these facts and acknowledging some key facts:
1. They had asked a contractor to perform a very
risky task on their electrical hazards.
2. They had a contractor that had qualified its
workers and what workers would be performing
what task.
3. What the limitations were for the workers –
PPE, training & rate of survival if an electrically
related incident was to occur.
4. Scales of responsibility, care and liability were
communicated in writing.
Basically the hospital; had to sign documentation that they
were responsible, liable and “could go to jail” if something
went wrong.
Even though there were a tremendous amount of
preparations made for the task of the energized demolition of
the existing cables, a new plan would have to be written for
the pulling and installation of the new cables as well. The
energized demolition work plan was never signed by the
hospital, as it realized it could not accept the liability
involved for such a hazardous task. At this point, the hospital
agreed to a twelve-hour outage for the end of the week.
E. The Outage
The outage was scheduled for a Friday night and was to end
on Saturday night at midnight. This was a full 24-hour outage,
just shy of a week from the initial event. The outage was
uneventful for the most part. The electrical testing contractor
and its contractors installed the remanufactured customer-
owned transition pieces into place and tied two of them into
3000 Amp bus connectors. The electrical testing contractor
performed insulation resistance testing phase-to-phase and
phase-to-ground and recorded satisfactory test results.
Contact resistance testing was performed end-to-end and
phase-to-phase from the utility side of the transition piece to
the line side of each service entrance switch and again
recorded satisfactory test results. The third customer-owned
transition piece was installed and thirty runs or about 2500 ft.
of 500 MCM cable were installed, terminated and electrically
tested with satisfactory test results. During this time the
electrical testing contractor assisted the generator support
personnel in removing all the temporary cables, while
maintaining all associated hospital-owned service entrance
switches and the placement of covers back on the switchgear.
Though the tasks went down to the wire time-wise, they were
error free, injury free and, at completion, the system was
deemed safe to energize.
F. Energizing
The electrical testing contractor worked closely with the
utility so they could verify the test results. The utility was not
satisfied with the testing contractor’s test data and chose a
different methodology of test to verify that it was safe to
energize the system. The utility placed a 6 A glass fuse across
the open bus terminals between the utility and the hospital
and energized each and every phase for a few seconds. A
blown fuse meant it is not safe to energize. This process took
about two hours and prolonged the outage beyond the
hospitals planned 24 hours. Once the equipment was deemed
safe to energize by the utility personnel, they began working
with the network management personnel to “close the system
in”. At this time the large fuses between the hospital and the
vault had not been installed. A utility worker who was
donning his arc-rated suit for the very first time to perform
this task made a comment that “he had owned this suit for a
year and never wore it”. That was evident, since it still had
the plastic extra-large sticker on the pant leg and plastic
manufacturer’s labels hanging off the jacket. These stickers
were never removed from the suit while in use by the utility
worker. After some quick discussions between the electrical
testing contractor and the utility workers management staff,
they were finally convinced by the testing contractor that
installation of 3000 Amp fuses while energized may not be
the safest method; the fuses were installed de-energized. The
vault was formally energized early Sunday morning around
6:30AM. Prior to the break of daylight and just a few hours
past the one-week anniversary of the original event all utility
power was restored to the hospital. See Figures 19 & 20.

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Figure 19 - Restored Low Voltage Vault Feeders to Overhead
bus with new lighting.
Figure 20 - Repaired Low Voltage Bus ducts in the hospital
power room
G. Regulatory Enforcement (Updated 9/2016)
OSHA performed their investigation at the disaster site.
Their summary and narration of events stated that; On May 2,
2010, Employee #1 and Employee #2 of Medical Hospital and
Employee #1 of Utility, were burned due to an arc flash and fire
while Employee #1 of Utility was opening a phase potential
switch from a “Load Break Switch” of 13,200 volts phase to
phase to perform the transfer switch. All Employees were
hospitalized and treated for their burns and scalds due to the
flash. No mention of the 4th
worker from the hospital was made
by OSHA since an actual hospitalization overnight did not
occur. The worker was treated for minor second degree burns
and released. OSHA ultimately issued seven (7) citations the
electric utility company. Citations issued were for
inappropriate PPE for the hazards, inappropriate electrical
work practices, no documented training for the hazards or the
task, no training and/or procedures for the task and bypassing
equipment interlocks or safeguards resulting in equipment
failure and injury to electrical workers.
a. Six (6) “Serious” citations were issued
a. Four (4) were issued at $6300 each
b. One (1) was issued at $0 amount
b. One (1) “Other” for $6,300.was issued as well for
defeating the electrical equipment’s safety interlocks and
mechanical safeguards.
Ultimately OSHA deleted all of the “Serious” citations and
“zero balanced” they as well abated the “Other” citation to
only a $3,100. “Other” than Serious.
Figure 21 – Examples of the citation schedule.
H. Today and the safety practices of those involved
Not much has changed since this event for the hospital or
the utility. The hospital has performed an electrical arc flash
hazard analysis on its distribution switchgear, labeled and
documented the equipment, but has not implemented any
standardized safety related electrical maintenance programs.
The company that performed the arc flash hazard analysis was a
low cost provider using a commercially available software. The
report that was issues made numerous assumptions about the
performance of the equipment and did not reference any
maintenance or frequency data. Much of the data gathered for
the arc flash study had to be assumed because prior electrical
performance data on the equipment was not available since it
had never been routinely performed in its 20 years of service.
The personnel have received some lecture and video electrical
safety training and provided their workers with some limited
PPE suitable for the arc flash/arc blast hazards downstream of
the “Main” low voltage switches, but the daily wear worn by
the staff is still a poly-blend professional wear. No PPE exists
for the workers to operate the main switchgear. N training on
the main switchgear has ever been performed.
The utility has seen a large amount of attrition of its
senior qualified field personnel and is working to replace
them as quickly as possible. New workers do receive
organized electrical safety and hazard awareness training with
focused on-the-job training is a. Much of the burden of
dealing with the hazardous operation, maintenance and repair

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of the equipment in the utility system has been passed on to
contractors. Some good, some bad. Not one contractor is the
same. The utility typically works with the lowest cost
provider. Safety is not a focus!
IV. CONCLUSIONS
The dilemma here is that a hospital charged with saving
lives can be discussing pushing a contractor to perform a
high hazard, high risk task and have no accountability for
safety of their workers, much less their patients and worst of
all it was never recognized at any point during the disaster.
The hospital still performed surgeries daily and managed
their emergency room as if the rental generator power was
just as reliable as the utility power. The refusal to plan
around generator maintenance routines proved extremely
costly for the hospital staff, as well as placed each and every
patent in jeopardy. Though the hospital touted that “we
need to do this as safe as possible” they never once engaged
with any of the electrical contractor’s about their electrical
safety practices, procedures or electrical worker
qualifications. They never attended one safety briefing.
Even after the submission of the energized work plan for the
removal of the cables, the hospital showed no interest in
interacting with the electrical contractors about safety,
maintenance or planning challenges that arose during the
outages. Many attempts were made by the electrical
contractors on site to directly inform the hospital’s facility
management and inform them that the electrical worker’s
lives were worth as much or more than the patients in their
hospital. This did not seem to sink in, nor did it ever
resonate with the hospital management. The hospital staff
was more worried about another inconvenient outage, not
taking an outage and requiring that risky energized work be
performed.
All utility and hospital workers survived their injuries and
are out of the hospital. The utility worker and hospital
administrator will have to undergo some additional medical
procedures in the future. Additional litigation ensued
afterwards.
It’s funny that we have known and used electricity in
some form since 1746. We didn’t understand the hazards of
shock and didn’t do something about it until 1972 with the
OSHA Act. We didn’t understand nor could we document
the hazards associated with electrical flash and blast until
1996 with the issuance of the IEEE 1584-2002. We clearly
didn’t understand how to safely work near, on, around or
interact with electricity until 2004 with the issuance of the
NFPA 70E. It took OSHA until 2007 to determine that the
NFPA 70E was a “necessary tool for the prevention of
electrically related death and injuries”. Its 2016 and the
NFPA 70E is the gold standard for protecting electrical
workers, establishing safety related maintenance routines
and dealing with PPE and task related tooling.
Regardless of the regulatory environment and limitations
to finding qualified workers you would think that protecting
our narrowing field of qualified electrical workers would be
the highest priority. Sadly the mindset of many contractors,
utilities, end users and electrical workers still has not
changed about how they train and protect their employees.
Mitigating shock and flash hazards does not seem to have
the appeal that it should.
V. ACKNOWLEDGEMENTS
Update (09/26/2016)
This is a modified IEEE Industry Applications Society
White Paper originally written and presented in 2012. This
updated paper and presentation includes the public details of
regulatory enforcement actions, general electric worker
recovery updates and additional details not made public at the
time of the initial publication of this paper. As a note, this paper
and the presentation were awarded “Best Case Study” for the
IEEE/IAS Electrical Safety Workshop in 2013.
VI. REFERENCES
VII.
1584-2002 - IEEE Guide for Performing Arc Flash Hazard
Calculations
NFPA 70E: Standard for Electrical Safety in the Workplace,
2015 Edition
VIII. ANSI/NETA: The 2015 Edition ANSI/NETA Standard for
IX. Maintenance Testing Specifications for Electrical Power
X. Equipment and Systems
XI.
XII. VITA
Mike Moore has been with Walker Engineering since early
2016. Prior Mike was the Vice President of Sales, Marketing
and Business Development. Mike Led Shermco through its
largest period of organic growth in its 40 year history. Mike
Left Shermco in 2013 after its sale to GFI Energy. Mike’s
experience includes project management on multiple large
and long term maintenance outages, disaster recovery projects
and startup services for Shermco Industries, Emerson Process
Management (eti/Electro-Test), National Switchgear Systems,
and Roundhouse Electric & Engineering Company. Mike is
qualified as an electrical safety & skills trainer training
commercial, industrial and government electricians,
technicians and engineers for the last 10 years. Mike is
currently a member of the International Association of

13. Revision 3, 2016 13
Electrical Inspectors (IAEI), the International Electrical
Testing Association (NETA), the Institute of Electrical and
Electronic Engineers (IEEE), Dallas Chapter of the
Independent Electrical Contractors (IEC), Past Marketing
Director (2008) and Membership Director (2006), as well as
current member of The Oklahoma Predictive Maintenance
Users Group (OPMUG), and Past member of the US Army
Infantry and US Army Persian Gulf Veteran.