TY - JOUR
AU - FRCS(C), Joel S. Fish, MD, MSc,
AB - Abstract The purpose of this study was to determine the circumstances of electrical burn injuries caused by the use of multimeters among electricians and electrical apprentices in Ontario and to develop a burn prevention program to reduce them. A survey to investigate electrical injuries caused by multimeters was mailed in June 2004 to 5000 Ontario electricians and electrical apprentices. A high voltage laboratory tested the effectiveness of fused leads to reduce multimeters malfunction. The results of the survey and laboratory tests helped to implement a burn prevention program. Then, a mail fused leads multimeter exchange program was implemented, and proposals to improve the multimeters standard were made to the Canadian Standards Association. Nine hundred (18%) workers responded the survey. There were 801 (89%) electricians, 81 (9%) electrical apprentices, and 27 (3%) with other qualifications. Ninety-nine (11%) had a multimeter fail during use, and half of them suffered critical burns. Causes of the injury were operator error (59%), wrong category rating (21%), defective equipment (18%), and others (2%). More than 2000 electrical contractors acquired the new fused leads multimeters. There were no critical injuries caused by multimeters in the years 2006, 2007, and 2008 (January to August) in Ontario. Understanding the cause of electrical burn injuries by multimeters and engaging members of the integrated electrical safety system in a multifaceted prevention program were effective in reducing electrical burn injuries. Fused leads multimeters proved to be effective in preventing most common user errors and electrical burn injuries caused by multimeters. A multimeter is an electronic multifunction device used to measure resistance, current, and voltage. Most electricians use handheld multimeters to trouble shoot electric circuits and verify the presence or absence of electricity before working on electrical circuits or equipment. In Canada, multimeters are constructed and tested following safety requirements of the Canadian Standards Association (CSA) for electrical equipment in measurement, control, and laboratory use (CAN/CSA 22.2 No. 61010–104).1 This Canadian National Standard is harmonized with the International Electrotechnical Commission Standard 61010-1:2001 MOD.2 There were 26 reported electrical burn injuries cause of the use of multimeters among electricians and electrical apprentices in Ontario between 1998 and 2005.3 In 2002, the Ontario's electrical safety code was amended requiring the mandatory reporting of serious electrical incidents to the electrical safety authority (ESA). Thus, the ESA was able to perform in-depth investigations from a root cause perspective, focusing specifically on the electrical factors. During these investigations, a trend involving multimeter accidents quickly emerged and alarmingly revealed that ∼80% of the reported multimeter accidents resulted in critical injuries to the victim.3 The investigation into these incidents pointed to user error as the action that initiated the incidents. Five common causes of user error were identified: wrong settings (ie, ohms scale selected when testing voltage), misapplication of the meter (ie, a meter with the wrong category rating was used), wrong probe socket used (ie, amperes instead of volts), wrong use of the product (ie, switching settings under power), and wrong voltage applied (ie, exceeding limits of meter). In most cases, it appears that although the initial fault itself did not cause the injury to the user, the multimeter had introduced the fault directly into the system being tested. As a result, a dead short was initiated right at the test probes' ends. This is the equivalent to putting a coat hanger right across the terminals being tested, with the victim standing within a one-half meter or so of the failure point. The selector switch on the multimeter was changed while the nonfused probes were on the live terminals. With typical fault currents in industrial applications well >10,000 A, and the resultant arc-flash temperature up to 35,000°F, it is not hard to see why there are so many critical burn injuries associated with these accidents. These faults typically occur in electrical equipment surrounded by a metal enclosure. The metal box directs the arc flash toward the electrician who is usually standing or crouching within a half-meter distance to the enclosure. In many cases, the victim was not wearing appropriate personal protective equipment. One such example is illustrated in Figure 1, which shows a fifth-year apprentice who was testing fuses on a 30-ampere circuit. The leads were in the wrong slot. The photographs that were taken few minutes after the incident show limited damage to the multimeter, significant damage to the electrical equipment being tested, and severe injuries sustained by the worker. The purpose of this study was to determine the causes of these injuries and to develop a burn prevention program to reduce them. Figure 1. View largeDownload slide Equipment damage and personal injuries from a multimeter failure incident. Figure 1. View largeDownload slide Equipment damage and personal injuries from a multimeter failure incident. MATERIALS AND METHODS Electricians Survey A mail-out survey was developed to better understand the scope of the multimeter problem and verify the primary causes of failure. This multiple-choice survey was mailed in June 2004 to 5000 Ontario electricians and electrical apprentices affiliated with the International Brotherhood of Electrical Workers. The survey investigated electrical injuries because of contact with a 347-volt lighting systems, the use of multimeters, the circumstances of electrical injury, and the respondent's level of training. Three questions specific to multimeters were included in the survey. The first question sought to quantify the extent of multimeter use by electricians. The second question asked if the respondents ever had a multimeter fail violently during use. The third question asked to those who had experienced a multimeter failure to provide information of the cause of the failure. Best Practice Review Broadly, one can divide the electrical industry into two segments. One part of the industry, the construction and maintenance segment, which constructs and maintains electrical installations and equipment associated with buildings. The other part, the utility segment, which constructs and maintains electrical installations and equipment associated with the generation, transmission, and distribution of electricity. Discussions with utility industry managers about the multimeter issue revealed that they were not experiencing these types of multimeter failures. The reason was that they used fused leads with their multimeters (Figure 2). In fact, the Electrical and Utility Safety Association Rulebook, rule (120(4)) requires that “All voltmeters, and phase rotation indicators rated up to 750 V AC shall be equipped with fused leads or be otherwise suitably protected.”4 Figure 2. View largeDownload slide Multimeter with fused leads. Figure 2. View largeDownload slide Multimeter with fused leads. Technical Research Although fused lead multimeters appeared to be in common use in the utility industry, they were not commonly used or known within the construction and maintenance sector of the electrical industry. In fact, few if any fused leads products were commercially available. To this end, ESA contracted a high voltage, high current research laboratory to test the effectiveness of fused leads in handling internal meter failures. The intention of this project was to search for, obtain, and test available fused leads multimeters to make a recommendation for possible widespread use throughout Ontario in the anticipation of reducing possible worker injury. Common user error scenarios were tested first with fused leads multimeters and then without the use of fused leads. The test source was set up such that, with a bolted fault, the system delivered 25 kA at 600 V. Ambient temperature in the test cell was ∼5.3°C. Tests were conducted by placing the tips of the probes in the jaws of a 600-V meter base. The initial tests were limited to ¼ cycle or 2.08 milliseconds. The final set of tests was extended to eight cycles or 0.13 seconds. High speed and normal speed videos were taken of all tests, as well as still photographs using digital cameras. Burn Prevention Program From the results of the mail survey and the multimeters technical research, a multilevel burn prevention program was developed to: a) raise awareness of the safety issue associated with the misuse of multimeters, b) influence behavior change of electricians to take proper safety precautions and use fused leads multimeters, c) influence the product design and standard, d) introduce fused leads multimeters in a market place where no certified fused leads products were available, e) create a marketplace demand for the fused leads multimeters, and f) thereby, encourage manufacturers, distributors, and retailers to include fused leads multimeters as part of their product offering. The prevention program would rely on creating voluntary safety compliance through promotion, awareness, and education and stimulating marketplace demand and supply. If voluntary compliance measures were not effective in reducing incidents and injuries, a legislative or regulatory approach that would mandate the use of fused leads would be considered. Fused Leads Multimeter Direct Mail and Exchange Program A partnership was established among the ESA, a fused lead multimeter manufacture, and an electrical distributor to develop and implement an ESA- sponsored multimeter lead exchange program. As part of a direct mail campaign, a coupon for a free set of fused leads multimeter was sent to ∼4000 electrical contracting businesses across Ontario. In exchange for a set of old unfused leads multimeter, the contractor was given a free set of fused leads multimeter. The coupon could be redeemed at 1 of 42 electrical distributor locations across Ontario. Multimeter Standards We assessed the standard governing multimeters in Canada (CSA/C22.2 No. 61010) and found that it did not appear to adequately address many of these specific issues. This is not totally unusual because it is field experience that drives a lot of standard changes. That is why codes and standards are constantly being updated by experience gained in the field. RESULTS Mail Survey Nine hundred (18%) of the 5000 electricians and electrical apprentices responded the survey. There were 801 (89%) electricians, 81 (9%) electrical apprentices, and 27 (3%) with other qualifications. The first question indicated that 80% of electricians use multimeters, 7% indicated that they sometimes use multimeters, and 13% indicated that they did not use a multimeter. Ninety-nine (11%) of respondents had experienced a violent multimeter failure during use, and half of those failures resulted in critical burns to face, trunk, and extremities. The responses to the cause of the injury are shown in Figure 3. Operator error (49%) and misuse (10%) were reported by the respondents, respectively. Improper category rating (21%) is another form of user error. In these situations, the wrong type of meter was used for the portion of the electrical system being tested. Defective equipment was reported in 18% and other cause in 2% of the injuries. The survey verified the main causes of multimeter failure identified as a result of ESA's multimeter incident investigations.5 Figure 3. View largeDownload slide Causes of multimeter failure. Figure 3. View largeDownload slide Causes of multimeter failure. Multimeters Technical Research Nine multimeter models from eight different brand types were tested with and without fused leads. The multimeters selected represented a range of multimeters in common use by electricians, including some of the multimeter models that were involved in reported incidents. The investigation report concluded that “the use of a properly fused test probe is highly effective in preventing possible catastrophic results, should the multimeter be used in an inappropriate way or if the multimeter experiences an internal failure.”6 The only scenario in which the fused leads could not protect the user was an extreme overvoltage condition; this was due to the voltage limitations of the fuse itself. The tests captured with high-speed photography showed that the failure initially started at the multimeter but soon propagated to the electrical equipment being tested. The resultant arc flash is shown in Figure 4. Figure 4. View largeDownload slide Laboratory testing of nonfuse leads multimeters. High speed photography of arc flash fault 25,000 A 1/13th of a second. Figure 4. View largeDownload slide Laboratory testing of nonfuse leads multimeters. High speed photography of arc flash fault 25,000 A 1/13th of a second. Fused Leads Multimeter Direct Mail and Exchange Program Approximately 2000 (20%) contractors participated in the direct mail program and exchanged a set of old unfused leads multimeter for a new set of fused leads multimeter. Four major multimeter manufacturers and six electrical product distributors (with >50 outlets across Ontario) have introduced fused leads multimeters into the Ontario marketplace in response to the demand for this product. Equally important, many contractors purchased additional fused leads multimeters for the balance of the electrician work force. One supplier reported selling ∼1500 additional sets of fused leads multimeters as a result of the program. Education and Information A multilevel education and awareness campaign was developed that included a promotional safety brochure, a multimeter safety video, and a sample of multimeter safe work procedure. More than 10,000 pieces of this safety promotional material were distributed by ESA to the electrical contractor industry associations, and to safety organizations representing the construction, industrial, and utility sectors. Articles on fused leads and multimeter safety were printed in industry magazines such as Electrical Business, Electrical Contractor, Canadian Association of Fire Investigators Journal, and the International Association of Electrical Inspectors magazine.7,–10 Contractor Outreach Sessions Every fall, the ESA organizes meetings in numerous locations across Ontario with electrical contractors. More than 20 of such meetings were held reaching several hundred electrical contractors. The multimeter safety and fused leads messages, videos, and informations were included as part of these meetings. In addition, ESA arranges one-on-one meeting with its electrical inspectors and electrical contractors. The fused lead multimeters safety message was included as part of this discussion. There was extensive participation among electrical safety system participants. Contractor associations and safety organizations actively participated in the education and awareness building activities and the distribution of program materials. Demand for the multimeter video continues even today. Apprentice Outreach ESA sponsored 30 safety presentations at 9 Ontario Community colleges reaching >1000 electrical apprentices. Community colleges and electrical apprentices have responded positively to the safety presentations within increased request for the ESA to attend future apprentice sessions. Standard Change Proposal The ESA submitted proposals to improve the multimeter national standard. ESA suggested that the standard be revised to include a performance-based requirement that on failure of the multimeter there should be no consequence to the meter or the system being tested. A revision to the CSA standard for multimeters has been finalized and is set for introduction shortly. ESA was invited to present its findings and recommendations to a meeting of the International Electrotechnical Commissions 61010 Multimeter Standard Committee. The principle measure was with critical injuries and fatalities associated with the multimeter use among the electrical trade members reported by the Ontario's Ministry of Labour. There were no injuries in the years 2006, 2007, and 2008 (January to August) associated with the misuse of multimeters among electricians and electrical apprentices in Ontario.11 DISCUSSION This study shows the effectiveness of a burn prevention program in reducing the incidence of burn injuries due to the use of multimeters in the province of Ontario. This prevention program was based on a multilevel education program, a direct mail campaign with a coupon for a free set of fused leads multimeter, and a proposal to change the multimeter national standard. It is our understanding that this is the first report of burn injuries due to the use of multimeters in the medical literature. Sparrow12 identifies three core elements that describe innovative approaches to harm or risk reduction: a clear focus on results, the adoption of a problem solving approach, and the development of “collaborative partnerships” within industry, government, workers, and various associations. To better understand and engage all components of the integrated electrical safety system in this multifaceted preventive initiative, we developed a diagram that shows the range of participants and approaches available within the integrated electrical safety system in Ontario (Figure 5). Figure 5. View largeDownload slide Integrated electrical safety system in Ontario. Figure 5. View largeDownload slide Integrated electrical safety system in Ontario. The electrical system can be described by its main components. The “electricity supply system” is the portion that generates, transmits, and distributes electricity to the broad range of electricity “end users,” which includes electricity users in residential, commercial, industrial, agricultural, and institutional buildings and facilities. The final leg of the system is the “electrical products, electrical installations, and services supply channel.” This channel includes those people and organizations that design, manufacture, and sell electrical products, and those people and organizations that install, maintain, and service the end user's electrical installations and wiring systems. The multimeter incidents involving qualified electricians are included in this portion of electrical system. In contrast, workers in the “electricity supply system” did not report injuries associated with multimeter use attributed to the use of fused leads. Safety culture exerts an influence over the participants within the system. It forms “the environment within which individual safety attitudes develop and persist and safety behaviors are promoted.”13 In the case of multimeter incidents, it appeared that a culture had developed within the “electrical products, electrical installations, and services supply channel” accepting these incidents as a “normal and acceptable risk for electrical workers.” This is in contrast to the culture within the “electricity supply system” where the use of fused leads multimeter was common. The safety system participants (Figure 5) include a various levels of government that enact safety-related laws and regulations, and a number of regulatory bodies that administer these safety laws and regulations. In the electricity area in Ontario, the ESA exists as an electrical safety regulator. However, the Ontario's Ministry of Labour and the Office of the Fire Marshall also have intersecting electrical safety regulatory responsibility related to workplace electrical incidents and electrical fire incidents, respectively. Although a collaborative market-based approach was chosen as the starting point for the development and implementation of the prevention program, the possibility of a regulatory intervention, by mandating the use of fused leads multimeters, remained as an option if the safety improvements could not be achieved through “voluntary” approaches. This possibility was underscored when an Ontario employer was prosecuted, convicted, and fined $50,000 by the Ontario Ministry of Labour for violation of the Ontario Occupational Health and Safety Act requirements.14 In this situation, the employer pleaded guilty for failure to ensure the worker used adequate protective equipment and procedures while testing the voltage passing into the fuse box. Within Ontario's workplace safety system, there are a number of workplace safety organizations such as the Construction Safety Association of Ontario, the Industrial Accident Prevention Association, and the Electrical Utilities and Safety Association. These organizations exist to promote accident prevention and provide training and education to businesses and workers within their respective sectors. All three associations were engaged and participated in the distribution of fused leads multimeter education and awareness materials to their respective membership. The ESA was invited to present its multimeter safety program at the 2006 Industrial Accident Prevention Association's annual safety conference, which is the largest safety conference of its kind in Canada. The education/information portion of the system was engaged through the community college system to bring the fused leads safety message to electrical apprentices. To augment paid media advertisement and promotion, fused leads safety articles were written and published in a number of industry magazines.7,–10 National Standards System A cornerstone of electrical safety in Canada is the National Standards System. This system includes a number of organizations that develop electrical installation codes and the safety standards for the manufacturing and certification of electrical products. These codes and standards provide the technical requirements that electrical installations and products must meet to provide an acceptable assurance of safety. Multimeters standards change is taking longer than anticipated. ESA is sponsoring additional research to support its standards change proposals. ESA has commissioned an independent technical review of the latest version of the multimeters standard. Also, ESA has partnered with a utility company whose employees use multimeters daily to study the effects of multimeter aging, wear, and tear on multimeter safety. The purpose of this standard research is to determine if the standard adequately provides safety for the normal and expected usage conditions. Technical and Behavioral Research Advances in safety are often achieved through the development and commercialization of new technology or improved understanding of human behavior. Research and development in both areas is an important component of continuous safety improvement. After completion of the testing of multimeters with fused leads, the research laboratory commissioned to conduct these tests and planned an in-house program for the replacement of unfused leads for both in-house and field-testing multimeter equipment.15 Health Care Providing care to those injured is an important component of the safety system in terms of mitigating the impact of the incident and working toward rehabilitation and return to work of those injured in electrical incidents.16 The health care system can also provide valued research on the nature and extent of electrical injuries by understanding the root cause from a behavioral perspective and providing important information to be used in education and awareness campaigns that help shape the safety culture. The following are the lessons learned from this education and prevention program and the feedback from its participants. High Direct Mail Participation Rate Direct mail participation rates typically are in the 1 to 3% range,17 but can vary from as low as 0.25% to as high as 25%. A number of American utilities achieved participation rates of 10 to 12% for compact fluorescent light coupon programs.18 The participation rate in the direct mail coupon exchange program was 20%. This was based on the highly targeted and accurate mailing list of licensed electrical contracting businesses in Ontario and on the high value of the direct mail offer. Factors that may have limited redemption rates include the availability of distributor locations across Ontario and preestablished relationships between electrical contractors and electrical distributors. Although the distributor selected had 42 locations across Ontario, where the old unfused multimeter leads could be exchanged for a set of new fused multimeter leads, not all regions of Ontario were covered by the distribution network. In addition, many electrical contractors have preexisting and long-established relationships with the specific electrical distributors, usually based on the extension of credit terms and the convenience of the location. They would purchase supplies and materials most often from the same distributor. Participation rates may have been impacted where the contractors did not have a relationship with the particular distribution company chosen to support this promotion. Impact of Product Quality As part of this research effort, ESA identified key attributes for a fused lead product. This included the following features: 600-volt, 200,000-ampere Interrupting Capacity Class CC fuse; a fuse rejection feature that prevents the user from replacing supplied fuse with a lower rated fuse; a smaller diameter 2-mm tip that would fit into the slot of a North American style electrical receptacle; blown fuse indication to alert the user of a blown fuse; minimum category III or higher to ensure suitability for most commercial and industrial uses; shrouded or limited exposure tips to help prevent inadvertent contact with the probe tips; and certification to CAN/CSA 22.2 No. 61010–104 by an accredited certification body. To alleviate any concerns with the use of fused leads, a product that provided all of these features was chosen. There were no certified fused leads products available in the Canadian market. A product manufactured in Europe was modified to meet these specifications and was certified to meet the requirements of the Canadian standard. However, due to the newness of the product, some quality problems were encountered and reported by <20 of the fused lead recipients. Root-cause analysis of the problem identified the adhesive selected could fail under impact in conjunction with the extreme cold temperatures in Canada. Although the assembly passed CSA testing for shock and vibration, there was no requirement for a low temperature test condition. A substitute adhesive was used and the product design modified to include a mechanical connection. To overcome any negative perception, the product warranty was extended to 2 years and three notices were sent to fused leads recipients informing them of the potential problem and offering a replacement set. Although this issue did not impact initial participation, intervention was required to maintain industry momentum toward the use of fused leads multimeters and ensure continued confidence in fused leads. The program did generate market place response for fused leads multimeters by creating consumer demand and ensuring availability of supply. The introduction of fused leads multimeter to electrical contractors did result in additional purchases of fused leads multimeters by contractors for the balance of their workforce. Although the direct mail fused lead multimeter exchange program has ended, ESA has continued it awareness, promotion, and education activities. In conclusion, understanding the cause of electrical burn injuries due to the misuse of multimeters and effectively engaging all components of the integrated electrical safety system in a multifaceted prevention program were effective in reducing the occurrence of serious electrical burn injuries. Fused leads multimeters proved to be an effective method in preventing most common user error scenarios and most electrical burn injuries because of multimeter internal failures. REFERENCES 1. Safety Requirements for Electrical Equipment for Measure Control and Laboratory Use. CAN/CSA 22.2 No. 61010-104.  Ontario: Canadian Standards Association; 2001. 2. International Electrotechnical Commission Standard 61010-1:2001 MOD. 3. Ontario Ministry of Labour. Selected Electrical Incidents and Occurrences, Quarterly Reports, 1998–2005. Ontario, Canada: Ontario Ministry of Labour. 4. Electrical Utility Safety Rules. Ontario, Canada: Electrical and Utility Safety Association of Ontario; Revised August 2004. 5. 347 Volt/Multimeter Survey.  London: Accumen Research Group Inc; 2005. 6. Beresh RW. ESA Test Probe Investigation. Report No.: K-012700-RA-0001-R00. Toronto, Canada: Kinetrics Inc.; February 2, 2009. 7. Smith S Multi-meter accidents and user error. Electrical Business Magazine  2005; 41: 26. 8. Multi-meter accident prevention plan. Ontario Electrical Contractor  2006; 44: 8– 10. 9. Smith S. Multimeter accident prevention plan, a fire investigators survival guide. Canadian Association of Fire Investigators 2007;Fall:22–3. 10. Smith S Multimeter accident prevention plan, an electrical inspector's survival guide. International Association of Electrical Inspectors News  2008; 80: 70– 5. 11. Ontario Ministry of Labour, Selected Electrical Incidents and Occurrences, Quarterly Reports, 2006, 2007, and 2008 (January to August). Ontario, Canada: Ontario Ministry of Labour. 12. Sparrow MK The Regulatory Craft Controlling Risks, Solving Problems and Managing Compliance.  Massachusetts: The Brookings Institution; 2000; 100. 13. Mearns K, Whitaker SM, Flin R Safety climate, safety management practice and safety performance in offshore environments. Saf Sci  2003; 41: 641– 80. Google Scholar CrossRef Search ADS   14. Ontario Ministry of Labour News Release, 05-146. Ontario, Canada; December 21, 2005. 15. Beresh B Kinetrics—Proactive Partner in Advancing Industry Safety.  Toronto, Canada: Kinetrics Inc; 2007. 16. Theman K, Singerman J, Gomez M, Fish JS Return to work after low voltage electrical injury. J Burn Care Res  2008; 29: 959– 64. Google Scholar CrossRef Search ADS PubMed  17. Canadian Marketing Association Direct Mail FAQs; available from http://www.the-cma.org/?WCE=C=47%7CK=225534; Internet; accessed February 2, 2009. 18. Pye ME, Nadel SM Compact fluorescent lighting: a review of DSM programs with high participation rates. Energy for Sustainable Development  1994; 1: 39– 41. Google Scholar CrossRef Search ADS   Footnotes 1 Presented in part at the 14th Congress of the International Society for Burn Injuries in Montreal, Quebec, Canada, September 7–11, 2008 and in part at the Annual Meeting of the Canadian Special Interest Group of the American Burn Association, San Antonio, Texas, March 23, 2009. Copyright © 2010 by the American Burn Association
TI - An Effective Prevention Program to Reduce Electrical Burn Injuries Caused by the Use of Multimeters
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0b013e3181d0f5cb
DA - 2010-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/an-effective-prevention-program-to-reduce-electrical-burn-injuries-hcTNssPVDR
SP - 333
EP - 340
VL - 31
IS - 2
DP - DeepDyve
ER -