Rachel Rosoff, a senior at Enloe High School, was on duty and alone when a fellow employee showed up for work and found her floating face down in the water on Sept. 3.
The report outlines everything investigators uncovered at Heritage Point Pool.
Read the full report here (.pdf)
The pool was installed and permitted in 1979. Since then, no other construction permits have been filed.
The inspector cited a number of actions that, while unpermitted or not up to code, did not lead to the water being electrified.
Among them, he found an unknown contractor repaired the electrical feeder to the pump in 2011 without the required permit.
Also, a motor bonding wire had been cut and loosely wrapped around the equipment bonding wires, which does not comply with National Electrical Code.
Read more about the incident here.
In his conclusion, the inspector found the pool pump motor failed and when it faulted to ground, the grounded conductor was broken, causing the current to travel into the water and pool equipment.
"Since this conductor was open (broken) it could not conduct the necessary current to cause the overcurrent device (breaker) to open (trip)," Gregory Vance, Inspections Administrator, wrote. "The fault current then followed the only path available to it, the pool water, creating a voltage gradient across the pool and pool equipment."
The investigation was conducted at the request of the Wake County Sheriff's Office.
The NC Department of Labor, Occupational Safety and Health Division is also carrying an investigation to find whether safety or health standards were violated at Heritage Point Pool.
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