Sale of Cllilnrni:

 

 

 

 

 

DEPARTMENT OF INDUSTRIAL RELATIONS 
DIVISION OF OCCUPATIONAL SAFETV AND HEALTH
Carrier
NARRATIVE SUMMARY
Name Tesla M01015, In: Impemlan 1012976
Number

Tm: Manager

Conlaued

Samanlha Erichacek

Informalion on [muted Covered by Compensalvon Vcs_X_ No,

Name' Address and Phone Number Occupation

 



Facniuy Tech
Maintenance

 

 

 

 

 

addinunal forums) as needed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

vacss Nan-Ms) and Tulle 'ChecL hm precedmg name xfcanfidcmialny i> given.
Names and Title(s) Address Phone No. Signed smemenw
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Facfluy mm. 
Yes No
Faciluy Mainlcnance 
-- 
cmyluy Maintenance 
Summary
Please see anached
Us: addiuonal shch(s) as needed.
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Reviewed by' DM NW7) SI 
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Tesla Motors, Inc.

(1012976)

On November 30, 2014, at approximately 3:13pm, Facilities Technician (employee) received electrical
flash burns to arms, shoulder, back, face, laceration to back of head, and loss of consciousness from fall
to the ground while cleaning inside an energized high voltage electrical panel. Tesla Motors, Inc.
employs employee at 45500 Fremont Blvd., Fremont, CA. The employee was transported via ambulance
to Santa Clara Valley Medical Center located at 751 South Bascom Ave., San Jose, CA. The accident was
reported via phone on November 30, 2014, at approximately 8:52pm by Patrick Weatherall, Supervisor.

Investigation into the accident was begun on December 8, 2014, held opening conference with
Samantha Brichacek, Manager. The employer is engaged in automobile manufacturing. At the time of
the incident, the employer was engaged in maintenance and cleaning of electrical equipment inside
substation. At the time of this inspection, the scene and equipment had been changed.

The scene is located inside electrical Substation #17. The equipment is a Type HVL Load lnterrupter
17A11, 12kV high voltage switch gear feeder with (low and high voltage). The employee was using a
"Dustin" polyester ?bers electrostatic duster owned by Electra?Link Engineering Services, inc.

On the day of the incident the facilities workers and contractor were performing cleaning/maintenance
inside the substation #17. They started work between 6:30 am and 7:00am. The power to the switch
gear was de-energized in the morning by Tesla supervisor, and workers racked breakers and started
cleaning/testing inside the sub-station. The crew and contractor took lunch between 11:30am and
2:00pm and were notified during lunch by supervisor that the 12kv electrical system needed to be re-
energized. The Supervisor made noti?cation at the table with everyone eating. The employee and
other workers did not hear the notification.

The power to the substation electrical system (high voltage switch feeder) was re-energized. The crew
started back cleaning on the de?energized 480 volt electricai panel (back side of the equipment). They
finished cleaning and W1 gave instructions to the victim to clean the inside of 12 kV electrical panels.
The employee opens the unboited door and with his right hand starts using the duster (feather) cleaning
tool near the three phase high voltage bus bar. The duster (particles on duster) cause a static electric
charge between the phases inside the panel and an arc flash occurred. The employee was knocked to
the ground, and co-workers responded to the scene/equipment.

Tesla Motors, Inc.

(1012976)

Action/Conclusion

Failure to implement -failure to conduct inspection (job analysis for the maintenance/cleaning)
inside the electrical room and panel General 3203(a)(4)

Failure to develop written procedures hazardous energy control procedures for electrical switch gear 
General 3314(g)(2)(A)

Failure to communicate to all employees on re?energizing the high voltage equipment Serious 
3203(a)(3)

Failure to provide training and instruction all employees on high voltage Serious 3203(a)(7)

Failure to conduct visual inspection and tests prior to cleaning inside high voltage electrical panel -
Serious 2944(h)(1)?

Failure to furnish safety devices (personal protection equipment) and safeguards for working inside high
voltage electrical panel Serious - 2940(b)

Failure to utilized warning tags or locks Serious T8CCR