NIOSH In-house FACE Report 2004-07 |
December 23, 2004 |
Summary
On July 27, 2004, a 46-year-old chain saw operator (victim) was cutting
root balls from trees pushed over during site clearing, when he sustained
fatal crushing injuries after being struck by the bucket of a track-mounted
hydraulic excavator. The excavator operator was using the bucket on the
excavator to push over trees, straighten downed trees for stumping, and
move damaged trees to a large burn pile. When he realized he had not seen
the victim for approximately 15 minutes, he moved the excavator to get
a better view of the area and saw the victim on the ground. He jumped
out of the excavator and ran to the victim. Unable to get a response when
he called to the victim, he ran to his employer who called 911 on his
cell phone. The employer drove to the main road to help emergency medical
service personnel (EMS) locate the incident site. Police officers responded
within minutes and the excavator operator accompanied them to the incident
site. The victim was pronounced dead at the scene at 10:30 a.m. by EMS
personnel.
NIOSH investigators concluded that, to help prevent similar occurrences,
employers should
- ensure that the phases of work are planned and executed to minimize
the exposure of workers on foot to moving equipment
- ensure that excavator operators and workers on foot maintain visual
or audible contact at all times
- develop, implement, and enforce a comprehensive written safety program
for all workers which includes training in hazard recognition and the
avoidance of unsafe conditions. A written training plan should require
training for all excavator operators that includes the equipment manufacturers’
recommendations for safe equipment operation, and should require appropriate
training for workers engaged in site clearing and logging operations.
- provide workers with appropriate personal protective equipment (PPE)
and ensure its use.
Additionally,
- general contractors should ensure through contract language that all
subcontractors have appropriate safety programs and training specific
to the work to be performed.
Introduction
On July 27, 2004, a 46-year-old chain saw operator (victim) was cutting
root balls from trees pushed over during site clearing, when he sustained
fatal crushing injuries after being struck by the bucket of an excavator.
On August 12, 2004, the North Carolina Occupational Safety and Health
Administration (NCOSHA) notified the National Institute for Occupational
Safety and Health (NIOSH), Division of Safety Research (DSR) of the incident.
On August 17, 2004, a DSR safety and occupational health team met with
the NCOSHA compliance officer assigned to the incident. The DSR team accompanied
the NCOSHA compliance officer to the site, took photographs, and interviewed
a landscaping subcontractor who had been working at the site on the day
of the incident. The DSR team interviewed the victim’s employer
by phone on August 18, 2004. The excavator operator was not available
for interview. The police report and medical examiner’s report were
reviewed. The cause of death was obtained from the medical examiner.
Employer: The victim’s employer
was a grading and hauling subcontractor. According to the employer, he
was hired to clear the site because the general contractor had not been
able to find a logging company to log the trees (primarily pines about
12 inches to 18 inches in diameter and 28-30 feet high) on a 14 acre site.
His typical work consisted of grading and hauling operations, but clearing
a few trees on residential building sites was done on occasion. The company
employed 7 workers and had worked exclusively for the general contractor
over an 8 year period, six weeks at the incident site. The company had
no safety and health program and no documentation of employee training.
There was no written agreement between the general contractor and the
subcontractor regarding safety issues.
Victim: The victim worked for the subcontractor for 2 months as
a chain saw operator. He had worked six weeks at the incident site. His
job was to cut the root balls from downed trees and to cut the trees in
to sections. His previous employment experience and training is unknown.
Equipment: The hydraulic excavator had been purchased by the grading
subcontractor and was five years old. The excavator’s reach capacity
was between 32 and 34 feet at ground level. A hydraulic thumb (photo
1) had been attached to the excavator so that it could be used for
handling felled trees. The equipment operator had been employed by the
company for 7 years and operated this excavator and other heavy equipment
on a regular basis.
Personal protective equipment: The employer had a truck on site
in which several hard hats, hard hats with face guards and ear muffs (hearing
protection), and a pair of chaps for leg protection were located. This
was the employer’s first fatality.
Investigation
The incident site was being developed into a recreational sports complex
with both indoor sports facilities and outdoor ball fields. On the day
of the incident, two subcontractors were working on the land: a landscaping
subcontractor who was involved with a roadway inspection at one end of
the 14-acre property and the grading and hauling subcontractor who was
working with a crew of two employees (excavator operator and victim) doing
site clearing at the other end. The grading and hauling subcontractor
and his crew had cleared brush and 28-30 foot pine trees from 10 acres
and was ahead of schedule, with 4 acres remaining to clear.
According to the grading and hauling subcontractor, his employees rode
to work together from his shop located about 50 miles away. Work typically
began at 7:30 a.m. and ended at 5:00 p.m., Monday through Friday. On the
day of the incident, work began at 7:30 a.m. While his two-man crew started
site clearing, he drove to another worksite, returning at approximately
9:45 a.m. The victim spent his first hours of the day cutting root balls
(stumping) from downed trees with a chain saw. He wore a shirt, blue jeans,
hiking boots, and a baseball cap. He was not wearing any type of personal
protective equipment. The excavator operator reported to the NCOSHA compliance
officer that he took down trees the first few hours of the day, moving
ones that were to be burned to the burn pile and straightening others
so they could be stumped by the victim. When he got to a location where
he thought the victim might be in danger, he would blow the horn, open
the door and holler for him to move.
The victim and excavator operator took a 10 minute break at about 9:30
a.m. After their break, the victim returned to cutting stumps and the
excavator operator walked approximately 300-400 feet away to help put
oil in the bulldozer that his employer was preparing to operate. The employer
then started to push brush toward the burn pile with the bulldozer. The
excavator operator reported to NCOSHA and police investigators that after
he helped his employer, he got back on the excavator and resumed work
pushing over trees, lining up trees for stumping, and moving waste to
the burn pile. After about 15 minutes, he realized he had not seen the
victim since he had resumed work. He moved the excavator forward and turned
it to the left and saw the victim’s foot through the side window
of the excavator. He set the bucket on the ground and got off the excavator
and ran to the victim calling his name. Unable to get a response from
the victim, he ran to his employer who called 911 on his cell phone. It
was approximately 10:22 a.m. The employer drove to the main road to help
EMS personnel locate the incident site which was approximately 1/8 mile
off the main road. Police officers responded within minutes and the excavator
operator accompanied them to the incident site. One of the responding
firemen indicated he was first on the scene and noted that the victim
appeared to be dead. He was lying on his side with his body doubled over
at the waist and his torso appeared compressed. EMS personnel responded
and determined that the victim had died. The victim was pronounced dead
at the scene at 10:30 a.m. by EMS personnel.
According to statements taken from those who responded to the incident,
the victim’s body was found beside a downed double tree (two trees
on one root ball). One of the trees on the double tree had been cut from
the stump and the other had a superficial saw cut on it. The chain saw
was located under the victim’s body as was a large limb. The switch
was in the “on” position and the chain brake was not engaged.
The employer reported that he thought the double tree may have rolled
and struck the victim when it became unbalanced after the victim had cut
one of the trees on the double tree. The excavator operator told the NCOSHA
compliance officer that he did not believe he had struck the victim with
the bucket.
Photographs of the site taken immediately
after the incident indicate that the victim’s body was found in
an impression approximately 18-20 inches deep. There was a downed double
tree with a large single root ball between the victim and the excavator.
It is unlikely that the victim was visible to the excavator operator because
of the site characteristics and because the victim wore dark clothing
and was bending over to cut downed trees. Distance estimates made by NCOSHA
indicate that the victim’s body was located within reach of the
excavator bucket. Police personnel noted marks on the victim’s body
that they believed were made by the bucket of the excavator.
Cause of Death
The medical examiner’s office reported that the cause of death
was blunt force injuries due to a backhoe accident.
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Recommendations/Discussion
Recommendation #1: Employers should ensure that the phases of work are
planned and executed to minimize the exposure of workers on foot to moving
equipment
Discussion: The site clearing and tree harvesting work conducted on the
incident site involved pushing over trees and brush with an excavator
bucket and separating downed trees that were to be cut and sold for saw
timber from those that would be burned as waste. Employers should inspect
the worksite and plan work tasks in phases to eliminate the need for workers
on foot, such as chain saw operators, to be working in an area where machines
are being operated. All phases of work should be planned to maintain required
distances between workers and machines and between various machines operated
on site. NCOSHA has a special emphasis program (SEP)a
for tree felling and related activity that identifies the federal OSHA
logging standard as applicable to the type of work performed in this incident.1
OSHA Logging standard 29 CFR 1910.266 (d)(6)(i) requires that employees
be spaced and the duties of each employee shall be organized so that the
actions of one employee will not create a hazard for any other employee;
29 CFR 1910.266 (f)(2)(vii) requires that machines be operated at such
a distance from employees and other machines such that operation will
not create a hazard for an employee.2
Recommendation #2: Employers should ensure that excavator operators and
workers on foot maintain visual or audible contact at all times
Discussion: Visual or audible contact must be maintained at all times
to ensure that safe distances are maintained between work areas and to
provide an opportunity to communicate information regarding working conditions.
Employers can ensure that workers understand this requirement for continuous
verbal or visual contact by requiring crews to discuss maintaining continuous
verbal or visual contact each day before beginning work. OSHA standard
29 CFR 1910.266 (d)(6)(iii) requires that each employee performing a logging
operation at a logging work site shall work in a position or location
that is within visual or audible contact with another employee.2
Recommendation #3: Employers should develop, implement, and enforce a
comprehensive written safety program for all workers which includes training
in hazard recognition and the avoidance of unsafe conditions. A written
training plan should require training for all excavator operators that
includes the equipment manufacturers’ recommendations for safe equipment
operation, and should require appropriate training for workers engaged
in site clearing and logging operations.
Discussion: A comprehensive written safety program should be developed
for all workers that is in compliance with applicable OSHA standards and
includes training in hazard recognition and the avoidance of unsafe conditions.
It should then be noted in a company’s comprehensive safety program
that certain types of training are required and when completed, the training
should be documented. For example, excavator operators should be trained
to use the equipment they are assigned to operate according to the manufacturer’s
specifications and recommendations. Workers on-site should be trained
to remain outside the established swing area and blind spots of excavators.
Additional information useful for training workers about hazards involved
with excavator use can be found in the NIOSH Workplace Solutions:
Preventing injuries when working with hydraulic excavators and backhoe
loaders3 available through the NIOSH
web site at http://www.cdc.gov/niosh
or by calling 1-800-356-4674.
The equipment manufacturers’ operating manual should always be
kept on the equipment and should be included in training for equipment
operators. The hydraulic excavator safety manual developed by the Construction
Industry Manufacturer’s Association (CIMA)4
can also be used to supplement and reinforce safety training found in
the manufacturers’ operators manual. For example, CIMA recommends
that excavator operators “KNOW THE WORKING
RANGE OF THE MACHINE. Be sure everyone is in the clear before swinging
or moving in any direction. NEVER swing or position attachment or load
over personnel or vehicle cabs. Never allow personnel
to walk or work under any part of the machine or load while the machine
is operating.”
Workers performing site clearing and logging operations should be trained
to recognize and avoid hazards associated with site clearing and logging
operations. Safety regulations can be found in 29 CFR 1910.266 Logging
operations.2 OSHA requirements for training
loggers are very specific and employers are required to certify compliance
with employee training [29 CFR 1910.266 (i) (1-11)].2
Appropriate safety training may have helped the excavator operator and
chain saw operator (victim) avoid hazards associated with working near
moving machinery, and hazards associated with stumping a double tree that
may roll toward a chain saw operator after one part is cut free. The OSHA
compliance officer observed the site shortly after the incident and reported
to DSR investigators that it appeared that the double tree had rolled
toward the victim.
Additional information useful for training workers about hazards involved
with logging operations can be found in the NIOSH Alert: Preventing
injuries and deaths of loggers5 available
through the NIOSH web site at http://www.cdc.gov/niosh
or by calling 1-800-356-4674. The worker/employer summary sheet can be
posted at the worksite or given to workers and may serve as an additional
means to communicate safe work practices to workers. OSHA has developed
a free internet-based training program for safety compliance with logging
standards that may serve as yet another means to communicate safe work
practices to loggers. This logging e-tool is available at http://www.OSHA.gov/SLTC/logging/index.html.6
Recommendation #4: Employers should provide workers with appropriate personal
protective equipment (PPE) and ensure its use.
Discussion: Employers should require employees to wear a high-visibility
vest or high-visibility clothing while working on a tree harvesting or
site clearing operation to help increase their visibility.7,8
The CIMA4 hydraulic excavator safety manual
recommends that excavator operators “always wear required protective
equipment such as hard hats, safety glasses, reflective clothing, safety
shoes, and ear protection, as required.” OSHA requires employers
to provide chain saw operators with leg protection constructed with cut-resistant
material and with foot protection that is cut resistant. Additionally,
employers must provide head, eye and face protection as well as hearing
protection. PPE should be inspected before initial use and before each
work shift. OSHA requirements for PPE in logging operations are located
in 29 CFR 1910.266 (d)(1)(i-vii).2
Recommendation #5: General contractors should ensure through contract
language that all subcontractors have appropriate safety programs and
training specific to the work to be performed.
Discussion: General contractors should require all subcontractors to
identify how they intend to implement a site-specific safety and health
program prior to starting work and make this part of the subcontract language.
The subcontractors’ safety and health program should be consistent
with the work to be performed and, at a minimum, meet all applicable OSHA
regulations.
a The scope of the tree felling SEP, identified
as Operation Procedure Notice (OPN) 88D, specifies that “Logging
activity includes limbing, bucking, marking, and cutting logs to length
as well as tree felling. Other operations covered by the OPN include,
but are not limited to, tree trimming, felling of trees in preparation
for the construction of roads or structures, clearing for agricultural
activity, saw milling, and storm debris cleanup and removal.” Applicable
Standards: “Employers who remove trees wholly or in part for which
there is a commercial use for the wood are covered by the 29 CFR 1910.266
logging standard. Employers covered by this standard include but are not
limited to loggers, arborists, and construction companies doing clearing
of construction sites where there is a commercial use of the wood.”
References
- The North Carolina Department of Labor, Division of Occupational Safety
and Health, Operational Procedure Notice 88D, Raleigh, North Carolina,
June, 1988.
- Code of Federal Regulations [2004]. 29 CFR 1910.266. Logging Operations.
Washington DC: U.S. Government Printing Office, Office of the Federal
Register.
- NIOSH [2004]. NIOSH Workplace Solutions: Preventing injuries when
working with hydraulic excavators and backhoe loaders. Cincinnati, OH:
U.S. Department of Health and Human Services, Public Health Service,
Centers for Disease Control and Prevention, National Institute for Occupational
Safety and Health, DHHS (NIOSH) Publication No. 2004-107.
- CIMA [1986]. Hydraulic Excavator Safety Manual for Operating and Maintenance
Personnel. Milwaukee, WI: Construction Industry Manufacturers Association
Form HE-60-1.
- NIOSH [1995]. NIOSH Alert: Preventing injuries and deaths of loggers.
Cincinnati, OH: U.S. Department of Health and Human Services, Public
Health Service, Centers for Disease Control and Prevention, National
Institute for Occupational Safety and Health, DHHS (NIOSH) Publication
No. 95-101.
- OSHA [1998]. OSHA Logging eTool. [http://www.OSHA.gov/SLTC/logging/index.html].
Date accessed: December 1, 2004.
- Fallers’ & Buckers’ Handbook 2001 edition. Workers’
Compensation Board of British Columbia, Vancouver, BC.
- ANSI/ISEA [1999]. American National Standard for high-visibility
safety apparel. New York, NY: American National Standards Institute,
ANSI/ISEA 107-1999.
Investigator Information
This investigation was conducted by Doloris N. Higgins, Safety and Occupational
Health Specialist, Fatality Investigations Team, Surveillance and Field
Investigations Branch, Division of Safety Research; and Gerard de Guzman,
MD, Occupational Medicine Resident at West Virginia University School
of Medicine assigned to NIOSH, Division of Safety Research, Special Studies
Team.
Photographs
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Photo 1. This photo illustrates the excavator
used at the incident site. [Photograph courtesy of NCOSHA].
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Photo 2. This photo illustrates
the location of the victim next to a double tree that rolled. The
excavator is not pictured but was located on the root ball side of
the downed trees [Photograph courtesy of NCOSHA]. |
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