The purpose of this paper is to present the manufacturing defect and damage pattern of a 3 phase 22.9/3.3㎸ oil immersed transformer, as well as to present an objective basis for the prevention of a similar accident and to secure data for the settlement of PL related disputes. It was found that in order to prevent the occurrence of accidents to transformers, insulating oil analysis, thermal image measurement, and corona discharge diagnosis, etc., were performed by establishing relevant regulation. The result of analysis performed on the external appearance of a transformer to which an accident occurred, the internal insulation resistance and protection system, etc., showed that most of the analysis items were judged to be acceptable. However, it was found that the insulation characteristics between the primary winding and the enclosure, those between the ground and the secondary winding, and those between the primary and secondary windings were inappropriate due to an insulating oil leak caused by damage to the pressure relief valve. From the analysis of the acidity values measured over the past 5 years, it is thought that an increase in carbon dioxide (CO2) caused an increase in the temperature inside the transformer and the increase in the ethylene gas increased the possibility of ignition. Even though 17 years have passed since the transformer was installed, it was found that the system’s design, manufacture, maintenance and management have been performed well and the insulating paper was in good condition, and that there was no trace of public access or vandalism. However, in the case of transformers to which accidents have occurred, a melted area between the upper and the intermediate bobbins of the W-phase secondary winding as well as between its intermediate and lower bobbins. It can be seen that a V-pattern was formed at the carbonized area of the transformer and that the depth of the carbonization is deeper at the upper side than the lower side. In addition, it was found that physical bending and deformation occurred inside the secondary winding due to non-uniform pressure while performing transformer winding work. Therefore, since it is obvious that the accident occurred due to a manufacturing defect (winding work defect), it is thought that the manufacturer of the transformer is responsible for the accident and that it is lawful for the manufacture to investigate and prove the concrete cause of the accident according to the Product Liability Law (PLL).