STATE OF CALIFORNIA DEPARTMENT 45% Fatality DIVISION OF OCCUPATIONAL SAFETY AND HEALTH Carrier NARRATIVE SUMMARY Establishment Inspection Name: San ?iego Gas 8: Electric Number 1048838 Management Contented: Title Curtis Cries System Protection Manager Norm Kohls, RE. Manager, Gas Technical Services Wiily Williamson . Field Safety Adviser Reena Roy Field Safety Terry Thedell, Plan, CIH, CSP Health Safety Advis or I A. Calders Senior Counsel Information on Injured Covered by Worker?s Compensation Yes No I BE Name, Address and Phone Number Banana-tinn- 1 Gas Patroller -- FT 25 years Witness Names(s) and Title Check box preceding name if con?dentiality is given. Name? Address and Phone Number Declination 2 Gas Patroller . 15 years Samoa: On Tuesday, March 3, 2-915 at approximately 3:20 PM, a- gas patroller for a: utility company in. San. Diego mffered serious injury when he fell about 7 feet into an imdergronnd vault. The regular employee of the employer suffered ?actures that required hospitalization and treatment. The Division was noti?ed of the accident by the employer on I 5 at 6 PM, Within 3 hours after the accident. 1 was assigned by use District Manager to investigate the accident on 5. The opening conference was held with the employer on 3130! 15, at approximately 2:00 PM at the accident site. The accident site and relevant. equipment. were. inspected,de photos. taken. The to. die aocidentwas iniendewed on 7:1 6/ 5. The accident victim. was interviewed on 7120f 15. The Union representatiire was present during the employee interviews. There was a single employee seriously injured in the accident. The accident victim, Employee was admitted to Sharp Hospital on 3283115 where he underwem treatment for the 3 fractured and pain management. The employee was hospitalized for about two days, and was released on The employer is a utility company that provides gas and electric service to homes and businesses in San Diego Canary. Employees in the Leak Mitigation Unit do routine patrols and inspections of underground gas lines, valves, vaults and gas meters at private homes and businesses. The employees panel the gas distribution and transmission system by various means including more vehicles and on foot. They use infrared gas detection units, both handheld and vehicle mounted, to Page 1 of 4 detect methane leaks, and prepare reports and work orders for repairs if needed. They also do visual inspection of above grossed systems. The gas patrolleis work from 6:36" AM to 3 PM. The area where the accident occurred is a fenced location off of Friar's Road, west of Via Las Gamble-s and east of Gaines St. (See Diagrams and Photos}. The two employees, EE #1 and EE #2 had been. perl'bm?ng a routine pipeline patrol at locations from Torrey Pines to Mission Valley. was training EE #1 on his regular job, as EE #1 had volunteered to learn his route in case someone needed to ?ll in for him. The employees of the Leakage and Mitigation Unit gathered for a daily safety tailgate meeting in the morning at their main cities at 6:33 AM, tlaen? calibrated- their tools and picked uptheir supplies to patrol the route starting at 7 AM. This survey reute generally takes 3 to 4 days to complete, and primarily consists of them driving over the pipeline route using a vehicle equipped udth a gas monitor device on the front bumper. The employees also have to stop periodically to survey regulator stations on foot. On Tuesday, 3-, the injured employee, BE and EE #2 arrived at the jobsite in the 6090- block of Friar's road at 3 :20 PM. RE #1 had not been to this location prior. EE #2 had been there four times per year on his regular route of inspections. The location is where underground 400 PSIG transmission lines and there- are valves and regulators ?rst the employees had to inspect. Friar?s road is a four lane boulevard that runs east-west, in this location there is a public golf course on the scrub side and businesses and oondorainhuns on the north side. In the utility easement on the north side, a few feet back from the sidewalk is a fenced in area, locked and visually obscured, by 32 feet. Inside the fenced area there are three aboveground valve cans, and an vault. The vault is 10 feet by 6 feet and 3 feet deep, with about a six inch above- ?groturd curb around the perimeter. Inside the vault were two deadended regulator valves (#844 and #843) which were no longer required to be inspected as part of the quarterly survey. At the time of the accident the opening to the vault was covered by three plywood sheets, each 3 feet by 5 feet. The sheets were 3.4 inch marine grade plywood, covered with ?berglass and painted. According to the employer?s incident were for weather protection, and not designed for? pedestrian or vehicle traf?c. There were no labelslon the covers indicating their load bearing weight or restricting access. It is possible that these were the original covers, installed as early as 1963. The covers were exposed to sun and the elements. There is also a ?xed ladder leading into the accessed by removing the panels. EE #2 had never stopped on me panels, and had not had causenoiremove the panels. The panels had been painted and sanded over the years, but EE #2 thought that they'were metal (as he was familiar with metal covers on other vatdts). HoWever EE #2 usually walked aron the perimeter of the vault when he checked the valves in the enclosure. He told EE #1 to use his infrared detector around the above ground valves and at the perimeter of the vault where there were gaps between the covers and the concrete. During this process, EE #1 chose to step onto the covers over the vault, which broke under his weight, and he fell into the vault, suffering serious injury when he landed on the valves and piping below. EE #1 had also thought at the time that the covers were metal. At the time of the inspection, the original covers Were still inside the enclosure, but the covers on the vault had been replaced with composite grated material, labeled that they can hold 4W lbs. The three original panels were found to be severely degraded. The one that had broken was creased in two, the ?berglass skin had split, and the interior wood material had degraded so that it was no longer- structurally sound. The other two covers were similarly degraded and appeared to be crumbling inside their ?berglass skin. According to the employer's incident report, an inspection of the vault covers in 26-16- had- indicated that the panels were bad and needed to be replaced. A work order was generated, but it was closed out without having been acted upon. In 2011 the valves inside the vault were considered to be dead end stubs and served no function. "On 1 Region Engineering advised Pipeline Operations that from a system control viewpoint it was not necessary to maintain these valves as critical valves, (and) at that point ongoing annual inspection of valves 843 and 844. was discontinued.? The other valves inside the enclosure continued to be impacted annually, but there was Page 2 of 4 no record that anyone had inspected the covers or the general safety of employees working in the of the vanlt. The enrpioyers report indicates that it was likely that no cover rehabilitation or replacement took place following the 2010 inspection and work order. Alter the opening conference and the initial of the area, the employer refased to allow the inspection continue on grounds of jurisdiction Following multiple conversations with DOSE legal, an inspection was ?nally obtained on 7/1515 and the inspection continued with a of the of?ce areas, equipment, trucks, employee interviews and review of safety programs and records on 16 and 7190:9015. The employer provided a edition 111?? and records of employee training. The 11131? was found to be suf?cient. There were no records of safety inspections at the location where the employees were working, but there were records that jobsite observations of gas patrollers was being done. They also have a written Heat Illness Plan, but there was insuf?cient detail in the plan, particularly how it applies to mobile crews and the speci?c provision of water and shade. The employer did have records of heat illness training training, and employees carry water and ice in their trucks, which can be replenished at district facilities in the areas where they're working. Their trucks are equipped with working air conditioning systems. There were records safety meetings provided. The employer an accident investigation on this accidern, and generated a highly detailed report with corrective recommendations identi?ed. At the time of the inapection, the corrective action had already been taken, and the hazard was The employer did report the accident to DOSE in a timely fashion. There were notices posted at the site, and all their employees have received trahaing in ?rst aid and CPR. The employer provided the OSHA 300 log requirements, and the fonn 5620 as requested. The contributing factors to the accident were a failure to have a cover over the vault roof meeting the requirements of being capable of supporting. 400 lbs, as well as being labeled and secured as required. REGULATORY ACTION ACCIDENT RELATED VIOLATIONS A Willful Serious accident related violation under Title Section 3212(b) could be established at this time. 8 CCR 3212(b) Floor Openings, Floor Holes and Roofs. Floor and roof opening oovors shall be designed by a quati?ed person and be capable of safely supporting the greater of or twice the weight of the employees, equipment and abated-ale that may be imposed on any one square foot area. ofthe cover at any time. Covers shall be secured in place to prevent accidental removal or displacement, and shall bear a pressure sensitized, painted, or stenciled sign with legible letters not less than one inch high, stating: ?Opening-Do Not Remove.? Markings of chalk or keel shall not be used. a) On 3/03/2015, an employee was seriously injured when he fell into a seven foot deep mdergrotrnd vault the opening of ndtich was covered with tince sheets of fiberglass covered plywood that were no longer structurally sound. Two employees were working at the valve #844 enclosure located in the 6900 block of Friar's read in San Diego, and whoa one of the elapioyee-s stepped onto the boards covering the opening. of the underground vault, the boards failed to holdhis weight and he fell through landing on the valve inside the concrete vault. The employee suffered Serious injury and was hospitalized for two days. Employees were exposed to a serious fall hazard from the opening that was not otherwise protected by guardrails. There were no markings or labels on the covers. ABATED Page 3 of 4 One other violation was found, a General violation for the elements of the Heat Illness Plan as per 3395636), baseti on the ole} sax-mm; The employer provided? an m?dat?d' versiet: of thevHeat {limes Plan per the revisions which took effect on May 1, 2015. However, since this inspection initiated prior to the effective date of those revisioes, the cited item was based or} the standard in effect at that time. Date I 2/ Reviewed . District Senior Other "Eel/0311A. DOA (us/ems; Page 4 of 4