California Department of Health Services
A summary
of this document is available in english and spanish.
(Un resumen de este documento está disponible en inglés y español.)
SUMMARY: CASE
192-549-01
A mechanical
cotton picker was stopped in a field. The machine driver and
his foreman were cleaning the machine's spindles. These spindles
pull the cotton off the plant and into the machine. They get
clogged with cotton leaves and twigs. To clean them, spindle
covers must be lifted off the spindles. On top of the machine
are power shafts, running from the engine to the spindles.
The
foreman told the driver to start the cotton picker. The driver
started the machine, but kept it out of gear. This meant that
the spindles were not turning, but the power shafts were.
They noticed a spindle cover was loose. The driver climbed
up on the machine to bolt it down. The driver's sweater sleeve
became caught in one of the turning power shafts. The sleeve
wrapped around the shaft and cut into his arm, almost taking
it off. He spent two weeks in the hospital, and his arm has
permanent nerve and muscle damage.
How
could this injury have been prevented?
- Never
work around unguarded power shafts.
- Fit
equipment with necessary safety devices, including guards
for power shafts.
- Employees
should not be asked to place themselves in dangerous positions.
BACKGROUND
On November
16, 1992, NURSE staff identified an injury in a cotton field
while reviewing records at a Regional Trauma Center. A 39
year-old Hispanic male cotton picker driver injured his arm
on November 11, 1992 while bolting down a spindle cover on
a mechanical cotton picker. An unguarded, rotating power shaft
caught his sweater sleeve and tightened the sleeve around
his arm. The sleeve cut into his arm and nearly amputated
it.
A nurse
from the NURSE Project interviewed the injured driver in the
hospital on November 16, 1992. On January 5, 1993, the senior
safety engineer from the NURSE Project interviewed the farm
labor contractor (the injured driver's employer) at the contractor's
field office and equipment yard. At this time, he examined
the mechanical cotton picker involved in the injury. NURSE
staff also reviewed the worker's hospital records.
The
California Occupational Safety and Health Administration (Cal/OSHA)
was not notified and did not investigate the incident.
The
incident occurred on a 200-acre cotton farm. The injured driver
had driven mechanical cotton pickers for the past six years.
His employer, a farm labor contractor, had been hired by the
farm owner to harvest a cotton field. The injured driver had
worked for him for one month. This farm labor contractor recruits
and manages workers for farm owners in a variety of crops
and tasks. He employs 6 full-time workers, 150 casual workers
(working 1-12 weeks per year), 50 seasonal workers (working
13-39 weeks per year), and 4 family members.
The
injured driver stated he had received formal, verbal safety
training, but the farm labor contractor could not give details
of the training. The farm labor contractor said he had a written
safety program, but it was not available for review by the
NURSE senior safety engineer. (As of July 1, 1991 the State
of California requires all employers to have a written seven
point injury prevention program: 1. designated safety person
responsible for implementing the program; 2. mode for ensuring
employee compliance; 3. hazard communication; 4. hazard evaluation
through periodic inspections; 5. injury investigation procedures;
6. intervention process for correcting hazards; and 7. provide
safety training and instruction. Title 8 California Code of
Regulations 3203.)
INCIDENT
On November
11, 1992, at approximately 11:00 a.m., the driver of a mechanical
cotton picker stopped his machine to clean plant debris off
the cotton picker's spindles. A mechanical cotton picker is
a large, self-propelled machine. Vertically rotating spindles
pull the cotton into rubber disks which remove the cotton
from the plant. The cotton is then vacuumed into a holding
basket at the rear of the machine. Rotating drive shafts run
from the engine to the spindles to power them.
The
foreman and the driver lifted the covers off the cotton picker's
spindles to clean them. Upon completion, the foreman wanted
to see if the rotating drive shafts were working properly.
He told the driver to start the cotton picker.
The
driver started the machine and put the drive system into neutral.
This kept the spindles from turning, but the drive shafts
rotated. They noticed a spindle cover was loose. The foreman
told the driver to climb up and lay down on the spindle cover
to hold it down and bolt it in place. After it was bolted,
as the driver was standing up, his sweater sleeve became caught
on an unguarded universal joint on the rotating power shaft.
The rotating shaft tightened the sweater, which twisted and
cut deeply into his upper arm.
The
foreman jumped into the driver's seat of the mechanical cotton
picker and turned off the machine. With the help of co-workers,
he cut the driver's shirt and sweater free from the shaft
and released his arm.
The
injured driver did not lose consciousness. Co- workers tried
to stop the bleeding from his arm with dirty and oily rags.
No members of the work crew were trained in first aid. He
was placed in a pickup truck belonging to the farm labor contractor
and transported to the emergency department of a local hospital.
This trip took approximately 23 minutes. He was then transferred
almost immediately by ambulance to a Regional Trauma Center
for treatment.
The
injured driver's upper left arm had a deep laceration caused
by his sweater twisting and cutting into his arm. His arm
sustained brachial nerve damage and extensive soft tissue
and muscle damage. After initial treatment in the emergency
department, the injured driver was taken to surgery to clean
and temporarily close the wound. A week later he received
a skin graft to close the wound. He was discharged from the
hospital 13 days after the incident. At the time of discharge
he was advised not to return to work for at least a month,
and to avoid strenuous activities.
PREVENTION STRATEGIES
- Standard
operating procedures should ensure that employees are never
required to intentionally place themselves in hazardous
situations to complete a work task. Standard operating procedures
should be explained in a comprehensive injury and illness
prevention program (Title 8 California Code of Regulations
3203: Injury and Illness Prevention Program). In this incident,
the foreman instructed the driver to climb onto the machine
in close proximity to unguarded rotating power shafts. A
method should have been selected which did not involve placing
a worker in this vulnerable position. If the worker had
not been on top of the machine, this injury would not have
occurred.
- Field
crews should have an adequate emergency medical response
procedure. The crew should have a cellular phone or radio
available to contact the Emergency Medical Services (EMS).
Crews should be trained to call 911 before moving an injured
worker. One or more members of the crew should be certified
in first aid and cardiopulmonary resuscitation (CPR) (Title
8 California Code of Regulations 3400(b): "In the absence
of an infirmary, clinic, or hospital in near proximity to
the workplace... a person or persons shall be adequately
trained to render first aid." Title 8 California Code of
Regulations 3439(b) "There shall be at least one employee
for every twenty employees any remote locations with training
for the administering of first aid"). In this incident,
if a crew member had been trained in first aid, and if a
cleaner rag was available at the injury site, he/she would
have known to use it instead of the dirty, oily rag to decrease
the likelihood of wound contamination.
- Employers
should evaluate their equipment to make sure that it incorporates
all modern safety features, and consider replacing or retrofitting
equipment to incorporate safety features. Even the newest
equipment available should be reviewed for guards and safety
devices. The manufacturer of the mechanical cotton picker
involved in this incident has since installed guards on
all the rotating shafts on the new machines. The manufacturer
has also installed a system which turns off all the machinery,
including the power shafts, when the driver steps off the
seat. If either of these safety features had been present
on this cotton picker, this injury might not have occurred.
FURTHER INFORMATION
For further
information concerning this incident or other agriculture-related
injuries, please contact:
NURSE
Project
California Occupational Health Program
Berkeley office:
2151 Berkeley Way, Annex 11
Berkeley, California 94704
(510) 849-5150
Fresno office:
1111 Fulton Mall, Suite 212
Fresno, California 93721
(209) 233-1267
Salinas office:
1000 South Main St., Suite 306
Salinas, California 93901
(408) 757-2892
Disclaimer
and Reproduction Information: Information in NASD does not
represent NIOSH policy. Information included in NASD appears
by permission of the author and/or copyright holder. More
NASD Review: 04/2002
This
document,
CDHS(COHP)-FI-93-005-27
,
was extracted from a series of the Nurses Using Rural Sentinal
Events (NURSE) project, conducted by the California Occupational
Health Program of the California Department of Health Services,
in conjunction with the National Institute for Occupational
Safety and Health. Publication date: March 1993.
The NURSE (Nurses Using Rural Sentinel Events) project is
conducted by the California Occupational Health Program
of the California Department of Health Services, in conjunction
with the National Institute for Occupational Safety and
Health. The program's goal is to prevent occupational injuries
associated with agriculture. Injuries are reported by hospitals,
emergency medical services, clinics, medical examiners,
and coroners. Selected cases are followed up by conducting
interviews of injured workers, co-workers, employers, and
others involved in the incident. An on-site safety investigation
is also conducted. These investigations provide detailed
information on the worker, the work environment, and the
potential risk factors resulting in the injury. Each investigation
concludes with specific recommendations designed to prevent
injuries, for the use of employers, workers, and others
concerned about health and safety in agriculture.
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