The Case of the Multimeter Meltdown

For a master electrician and his two assistants, working at a large food warehouse proved to
present continuous challenges. Although the uninterruptible power supply (UPS) used to
provide power to the communication antennas had been giving them problems for about a
year, most of the time these incidents were of little consequence. The team typically
corrected problems by simply cleaning a bad contact here and there. But on this particular
day, something much more serious was brewing. In this Forensic Casebook, the forensic
engineer investigates what led an experienced master electrician, who was troubleshooting
the electrical system, to use a 1,000V-rated multimeter to check voltage on 2,300V bus bars
a task that ultimately ended in serious third-degree burns.

The Case of the Multimeter Meltdown

Aug 18, 2014Lawrence Hmurcik and Sarosh Patel | Electrical Construction and Maintenance

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Master electrician troubleshooting electrical system in warehouse suffers third-degree burns after
using 1,000V-rated multimeter to check voltage on 2,300V bus bars.
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For a master electrician and his two assistants, working at a large food warehouse
proved to present continuous challenges. Although the uninterruptible power supply
(UPS) used to provide power to the communication antennas had been giving them
problems for about a year, most of the time these incidents were of little
consequence. The team typically corrected problems by simply cleaning a bad
contact here and there. But on this particular day, something much more serious was
brewing.

Photo 1. Multimeter is rated for measuring 1,000V, and it is blackened (burnt) as a result of measuring
close to 4,000V (phase-to-phase).

The facility, which operated as a transfer point for frozen food, served approximately
10 million people in an area serving several hundred square miles. Food came in by
train car and truck, got broken down into pallet-sized units, and was then loaded
onto trucks for shipment to local grocery stores. There were almost 1,000 employees
working on-site, including full-time employees, part-time employees, seasonal
employees, and external employees (workers for another company who brought its
product to the facility and helped unload it).

The scene
In the 1990s, the facility underwent an electrical retrofit (performed by outside
contractors) to get rid of some of the most outdated electrical switchgear and clean
up the remainder of the electrical infrastructure. Another outside contractor
maintained services for high-voltage electrical equipment required to power a
freezer.
The master electrician had previously served as an outside contractor and performed
electrical inspection work at the site prior to being hired as a full-time employee at

the warehouse. Although his staff of two assistants had some electrical training, they
were not licensed electricians.

The accident
On the day of the accident, the warehouse manager, who was the electricians direct
supervisor, was involved with welding work on the roof of the facility. After being
notified there was an issue with the UPS, he asked the electrician to investigate the
situation, advising him to trace the problems through the on-site electrical system
and report back.
Upon his initial investigation, the electrician found some minor problems, such as
dirty contacts on high power switchgear and capacitors (which he cleaned), and
voltages sagging below their nominal value (but nothing significant enough to merit
fixing). He worked fast because he wanted to get back and check on his staff, who
were in another part of the plant performing routine maintenance. For safety
reasons, he judged all voltages to be below 600V (nominal AC RMS); therefore, he
wore gloves rated at a nominal value of 600V.
He went to a lower level floor of the facility, which was the size of a football field and
housed dozens of electrical closets. While he was there, he opened one cabinet that
contained live circuits at 2,300V, RMS AC 3-phase. On this door and an adjacent
door to the same closet there were a few small signs indicating the high voltage
level, but the electrician unfortunately overlooked them as he went from one electric
closet to the next checking voltages. At one point in time, there had been many large
signs (affixed by adhesive) on the doors indicating the 2,300V rating of the circuits
contained within. However, these were all missing on the day of the accident. (At the
time of the incident, there was a gummy residue on the doors where the large signs
had been, but the original large signs themselves were never found.)
RELATED

The Case of the Misleading Meter

The Case of the Hurried Electrician
Once inside the high-voltage closet, he put one lead of a 1,000V-rated multimeter on
one bus bar and the second on another at which time a tremendous electric
current immediately traveled down the leads and incinerated the meter (Photo 1).
As a result, the victim received severe third-degree burns over a large portion of his
body, including his chest, stomach, arms, face, and back. Despite his serious burns,

the victim managed to stumble back upstairs where his coworkers saw him. They
administered in-house first aid within a few minutes, and he was in an ambulance
heading to the hospital within 12 minutes.

Photo 2. The large signs in red and white and black were NOT present on the door of the electrical cabinet
on the day of the accident. The small aluminum sign with black background was present on the
day of the accident.

The lawsuit
After the accident, the victim initially collected workmans compensation and then
began the difficult task of healing. Approximately five or six months later, the
plaintiff and his wife sued the owners of the warehouse, which proved to be six
different parties, including the building owner, parties renting the building for use as
a food warehouse, and the electrical contractor who had done the retrofit. The owner
wanted to sell the building; however, he could not do so until he was removed from
the pending lawsuit. Therefore, he hired a law firm that, in turn, brought us in as
forensic engineering experts to investigate the case.

Investigation and analysis

Photo 3. The small aluminum sign with black background appears in Photo 2, and it is blown up here.
Although it shows the voltage to be 2,300V, even magnified it is hard to read.

When we visited the site, it was almost a year after the accident had occurred. By
then, new signage had been put up on the high-voltage cabinets in question. Hence,
the photos in this article show the new signage, which was probably very similar to
what was actually missing on the day of the accident. In Photo 2, there is a small
aluminum sign with a black background, which was present on the day of the
accident. This sign, which is blown up in Photo 3, does clearly indicate the 2,300V
designation, but it is still difficult to read quickly. Also small, the grey-white sign
in Photo 4 was in place on the day of the accident.

Photo 4. Large signs in red, orange, black, and white were NOT present on the day of the accident. Only
the small grey-white plastic sign and the manufacturers identification plates were in place on that day.

During testimony, the plaintiff claimed that the cabinet was not locked on the day of
the accident the interlock mechanism (padlock) was missing. He also failed to
request any existing system/circuit information before he started troubleshooting,
even though a line wiring diagram of the system existed at that time. Obtaining such
information and system details should always be the first step in all types of electrical
troubleshooting. In addition, the plaintiff admitted that he did not notice either of
the two smaller signs on the closet doors. A trained electrician must read everything
and follow all available information/signage on a system/appliance before working
on it. Based on the evidence and testimony, we determined that the plaintiff failed to
follow proper protocols and read all relevant signs before proceeding to troubleshoot
the system.

The plaintiff testified that he had assumed the voltage was nominal 480V or less and
had no idea there was even a 2,300V source in that part of the building. He knew
that the 2,300V source existed in a small building apart from the main warehouse
that served the massive refrigeration units. However, because a private contractor
was responsible for monitoring and maintaining this isolated building, he assumed
any direct electrical hookups and monitors were all in the small building not in the
main warehouse.
The bottom line was that the job he was tasked with did not require him to be in this
area of the warehouse in the first place. He would have known this if he had looked at
the existing wiring diagrams. In addition, the plaintiff failed to inform his supervisor
of the areas he planned to troubleshoot beyond those originally assigned. The
warehouse supervisor, who depended on an outside contractor for maintenance of
the 2,300V electric source and the electric closet located within the warehouse (aka,
the closet where the accident occurred), would have informed the electrician that it
was this contractor, not the victim, who was responsible for the control of the
accident cabinet. If this wasnt enough, there were two more factors the plaintiff
failed to take into account.
He testified he was measuring the phase-to-phase voltage. This is the wrong protocol
for troubleshooting a 3-phase circuit. The phase-to-phase voltage is generally not
significant in the original trace of a troubled 3-phase circuit. The proper protocol
when measuring an unknown phase voltage in a 3-phase system is to place the
ground or common lead of the multimeter on the nearest ground point and then clip
the hot lead of the meter to one of the bus bars. Had the plaintiff done this, there
would most likely have been no accident, or there would have only been damage to
the multimeter. In this case, the phase-to-ground voltage was 2,300V, while the
phase-to-phase voltage was almost 4,000V.
The conductors and couplings of the 2,300V service were of a very large size
significantly larger than the ones that the electrician saw in the other electrical
closets for voltages of 600V or less. This should have been an additional red flag for
the plaintiff to rethink his next move. When asked about this, the plaintiff said he
thought the wires and couplings for the 2,300V source were greater than normal size
only because they were low voltage and high current, not the high voltage 2,300V.

The victims work boots and gloves were sufficient for voltages that he was
authorized to work on (i.e., 440V to 480V). These two PPE items most likely saved
him from electrocution and possibly death. He did, however, sustain very bad burns.
And although he recovered, he died one year later from complications of his injuries.

The findings
Based on our investigation, we determined with a reasonable degree of engineering
certainty that this accident involved gross negligence on the part of the plaintiff. We
maintained that he was ultimately responsible for the accident because he did not
behave in a professional manner or follow the proper protocols, including:
He did not obtain the available wiring information.
He did not have approval to work in that part of the facility.
He did not read the signs that were on the subject cabinet.
He did not de-energize the circuit he was investigating.
He did not follow proper troubleshooting protocol of measuring the phase-toground voltage rather than the phase-to-phase voltage.
We also found gross negligence on the part of the outside contractor, who completed
the retrofit at the warehouse, for not providing proper signage for the subject
cabinet. Furthermore, this contractor failed to ensure that the electrical interlock of
the incident cabinet was in place and functioning properly.

The outcome
The plaintiff did receive accident benefits and workmans compensation, but his
lawsuit against the warehouse owner took two years to resolve. Because he died
within the first year after the accident, his widow continued the suit. According to the
laws of the state in which this accident occurred, legal suits of this type went to a
governmental review board to deem them worthy or not worthy to go to court. The
review board dismissed the case without prejudice. The widow collected nothing
from the owner; however, we were told she was bringing another suit against the
contractor who serviced the electric closet and the 2,300V supply. Because we were
retained by the owner, our interest in the case ended with this judgment.

Hmurcik is a consultant at Lawrence V. Hmurcik, LLC. He can be reached

athmurcik@bridgeport.edu. Patel is presently a freelance consultant and instructor
at the University of Bridgeport. He can be reached at saroshp@bridgeport.edu.