NIOSH In-house FACE Report 2004-08 |
February 13, 2006 |
Summary
On May 18, 2004, a fifteen-year-old Hispanic youth died after entering
the hopper of a bark blower and becoming entangled in an auger. The victim
was a member of a two-man crew dispensing mulch onto the back yard of
a new residence in a housing complex. The self-contained, truck-mounted
bark blower had been filled to capacity with mulch at the company supply
yard and driven to the work site. The mulch was directed to the rear of
the bark blower by an auger/agitator and drag conveyor located near the
floor surface of the bark blower’s hopper. The mulch was then dispensed
by the bark blower through a four-inch, metal-reinforced flexible rubber
hose. The victim was directing the flow of the mulch through the hose
when the bark blower emptied. He was instructed by the foreman to walk
approximately 100 feet to the rear right side of the truck and turn off
and lock out the box that supplied power to the auger and blower, then
return the key to the foreman. When the foreman noticed after a few minutes
that the blower was still running, he walked to the rear of the hopper
and climbed a fixed ladder and looked inside. He saw the victim at the
bottom of the hopper entangled in the auger/agitator. He immediately ran
to a nearby residence and asked the owner to call 911. Emergency Medical
Service (EMS) and fire personnel arrived and determined this event was
a recovery mission. The bark blower was driven to a local fire station
where company mechanics and fire and rescue personnel extricated the victim’s
body. The county coroner pronounced the victim dead at the fire station.
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Photo 1. Bark blower involved in incident.
Photo courtesy of Maryland Occupational Safety and
Health Administration |
NIOSH investigators determined that, to help prevent similar occurrences,
employers should:
- conduct a hazard assessment of machinery to identify potential hazards
to which workers might be exposed
- develop, implement and enforce a comprehensive safety program, and
provide safety training in language(s) and literacy level(s) of workers,
which includes training in hazard recognition and the avoidance of unsafe
conditions
- develop, implement, and enforce a comprehensive written program for
work in permit-required confined spaces, such as bark blowers
- establish work policies that comply with employment standards for
youth less than 18 years of age in nonagricultural employment. Employers
should communicate these work policies to all employees
- ensure that machinery is operated in accordance with manufacturers’
specifications
- implement training programs targeted at youth workers which emphasize
the link between unsafe behavior and the potential for injury, and provide
constant supervision to younger workers
- ensure that restroom facilities or transportation to restroom facilities
are available for mobile work crews
Additionally manufacturers should
- consider and evaluate the installation of grid-shaped guards at the
top of bark thrower hoppers and over the auger and drag conveyor during
the manufacturing process. Ladder locks to prevent unqualified workers
from accessing the top of the hopper should also be evaluated and installed
if feasible
- consider affixing dual language labels with graphics to provide hazard
warnings and instructions for safe use of equipment
Introduction
On May 18, 2004, a fifteen-year-old Hispanic youth died after entering
the hopper of a bark blower and becoming entangled in an auger. On May
19, 2004, the U.S. Department of Labor, Wage and Hour Division, notified
the National Institute for Occupational Safety and Health (NIOSH), Division
of Safety Research (DSR) of the incident. On July 26-28, 2004, and on
August 23, 2005, a DSR senior investigator conducted an investigation
of the incident. The incident was reviewed with the Maryland Occupational
Safety and Health Administration (MOSH) compliance officer and the U.S.
Department of Labor, Wage and Hour investigator assigned to the case.
The company owner and coworkers were interviewed and the bark blower was
photographed. Photographs taken immediately following the incident by
the MOSH compliance officer were obtained. The cause of death was obtained
from the county coroner.
The employer was a landscaping service company that had been in operation
for 17 years and employed 20 workers, half of whom, including the victim,
were Guatemalan. The employer had a basic written safety and training
program; however, none of the employees had ever received training in
the use of personal protective equipment (PPE), confined space entry procedures,
or lockout/tagout procedures. All employees watched a video on the operation
of the bark thrower that was supplied both in English and Spanish by the
manufacturer. The video explained the operation of the bark blower, including
the steps to be taken to turn the machine power off and lock it out. The
employer participated in the Department of Transportation and state police
inspection programs whereby personnel from both entities performed periodic
inspections on the company vehicles, including the bark blowers. Company
mechanics also documented periodic maintenance on the vehicles. All vehicle
maintenance was performed in the company yard. New employees worked under
the constant supervision of the crew foreman during a one-week orientation
period. The employer supplied the workers with uniforms and safety equipment,
such as dust masks, when necessary. The Guatemalan workers spoke Spanish.
The company owner spoke English and Spanish.
At the time of the victim’s hire, his mother presented the company
owner with a birth certificate that identified the victim as being 17
years of age. The victim had worked for the company for three weeks. Although
his primary language was Spanish, he reportedly understood some English.
The victim’s foreman at the time of the incident was Guatemalan
and spoke only Spanish. This was the first fatality experienced by the
employer.
Investigation
The victim and a foreman were dispatched to a new private residence to
dispense mulch around various trees and shrubbery in the yard of the residence.
To dispense the mulch, the workers used a truck-mounted bark blower (Photo
1).
The bark blower was approximately eight feet wide, 15 feet long, 6½
feet high and was powered by an 80-horsepower diesel engine. The weight
of the bark blower was 8,000 pounds and its hopper had a capacity of eight
cubic yards. The mulch was dispensed through a blower with a capacity
of 830 cubic feet of air per minute at 12 pounds per square inch of pressure.
The bark blower had the capacity to dispense 15 cubic yards of bark mulch
per hour. The power box for the blower was located on the rear of the
passenger side of the hopper approximately 5½ feet above ground.
The blower was started by inserting the key, turning it to the on position,
then pressing the start button. The blower was deenergized by pressing
the stop button, then turning the key to the off position and removing
it from the power box. The sides of the hopper converged from seven feet
wide at the top to approximately three wide at the bottom. An auger/agitator
and drag conveyor were located at the bottom of the hopper (Photo
2). As the auger/agitator turns it breaks larger pieces of mulch into
smaller pieces that the drag conveyor carries to an opening containing
a feed roller. The feed roller then transports the mulch into a rotary
air valve that channels the mulch into a pressurized air stream created
by the blower. The mulch is then dispensed through a four-inch diameter
reinforced flexible rubber hose to the desired location.
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Photo 2. View of the bark blower from
the top of the hopper.
Photo courtesy of MOSH. |
When the workers arrived at the site at approximately 8:30 a.m., the
truck-mounted bark blower was parked on the side of the street, approximately
100 feet from where the mulch was to be dispensed. They then stretched
the flexible hose to the location where the mulch was to be spread. The
foreman energized the blower system with his key and started the blower
while the victim held the hose and directed the flow of the mulch. This
work continued throughout the morning with the two workers alternating
between holding the hose to direct the mulch and raking the mulch to a
level consistency.
Following lunch the workers resumed their work. Slightly after 2:30 p.m.,
the bark blower began to blow only air and the foreman determined the
hopper was empty. The foreman instructed the victim to walk to the bark
blower, turn it off, and return the key to him. The victim turned and
walked toward the truck. When the foreman realized the blower was still
running after a minute or two, he went to the blower and called to the
victim. When he did not receive an answer, he climbed a fixed ladder at
the rear of the hopper and saw the victim at the bottom of the hopper
entangled in the auger/agitator. He immediately ran to the residence and
asked the homeowner, who spoke Spanish, to call 911. Emergency Medical
Service (EMS) and fire personnel arrived and determined this event was
a recovery mission. The bark blower was driven to a local fire station
where company mechanics and fire and rescue personnel extricated the victim’s
body at 7:30 p.m. The county coroner pronounced the victim dead at the
fire station.
Cause of Death
The coroner listed the cause of death as multiple trauma.
Recommendations/Discussion
Recommendation #1: Employers should conduct a hazard assessment of machinery
to identify potential hazards to which workers might be exposed.
Discussion: Employers should conduct a hazard assessment of equipment
to identify any potential hazards to which the workers might be exposed
during operation, e.g., the rotating auger/agitator and the rotating drag
conveyor. Workers stated during interviews that at times they needed to
stand at the top of a fixed ladder at the rear of the hopper and try to
move materials from the sides of the hopper down to the conveyor with
shovels or pitch forks to allow materials to flow freely. In some instances
they stated they entered the hopper to try to kick large rocks or sticks
to move them. During OSHA interviews, the foreman working with the victim
stated that if no restroom facilities were available, members of his crew
would enter the hopper and use it as a restroom facility. Once the auger/agitator
and drag conveyor were identified as being hazardous, procedures should
be put in place that allow only qualified personnel to enter the hopper,
and then only after proper lockout/tagout procedures had been followed.
Recommendation #2: Employers should develop, implement and enforce a comprehensive
safety program, and provide safety training in language(s) and literacy
level(s) of workers, which includes training in hazard recognition and
the avoidance of unsafe conditions.
Discussion: Employers should evaluate tasks performed by workers, identify
all potential hazards, and then develop, implement, and enforce a safety
program that meets applicable Occupational Safety and Health Administration
standards addressing these identified hazards. The safety program should
include, at a minimum, worker training in hazard identification, and the
avoidance and abatement of these hazards.1
Companies that employ workers who do not understand English should identify
the languages spoken by their employees and design, implement, and enforce
a multi-language safety program. To the extent feasible, the safety program
should be developed at a literacy level that corresponds with the literacy
level of the company’s workforce. Companies may need to consider
providing special safety training for young workers or workers with low
literacy to meet their safety responsibilities. The program, in addition
to being multi-language, should include a competent interpreter to explain
worker rights to protection in the workplace, safe work practices workers
are expected to adhere to, specific safety protection for all tasks performed,
ways to identify and avoid hazards, and who they should contact when safety
and health issues arise.
Recently OSHA developed The Hispanic Outreach Module to assist
employers with a Spanish-speaking workforce in learning more about workplace
rights and responsibilities, identifying Spanish-language outreach and
training resources, and learning how to work cooperatively with OSHA.
In addition, the module provides a list of OSHA’s Hispanic/English-as-a-second-
language coordinators. These materials are available at
http://www.osha.gov/dcsp/compliance_assistance/index_hispanic.html2
or can be obtained by contacting an OSHA area office. OSHA contact information
can be found at http://www.osha.gov.
Information provided can be used by employers who are developing or improving
safety and training programs for their Spanish speaking employees.
Recommendation #3: Employers should develop, implement, and enforce a
comprehensive written program for work in permit-required confined spaces,
such as bark blowers.
Discussion: Although employees had received some on-the-job training,
they had not received adequate training based on OSHA requirements for
a permit-required confined space program, including training in control
of hazardous energy. The OSHA standards define a permit-required confined
space as a confined space that has one or more of the following characteristics:
- Contains or has a potential to contain a hazardous
atmosphere;
- Contains a material with the potential to engulf
someone who enters the space;
- Has an internal configuration that might cause
an entrant to be trapped or asphyxiated by inwardly converging walls
or by a floor that slopes downward or tapers to a small cross section;
and /or
- Contains any other recognized serious safety
or health hazard.3
Since the bark blower falls within this definition, a permit-required
confined space program is essential. Such a program has several requirements
which include but are not limited to:
- implement necessary measures to prevent unauthorized
entry;
- identify and evaluate permit space hazards (e.g.
atmospheric, mechanical, electrical, or other injury hazards) before
allowing employee entry;
- establish and implement the means, procedures,
and practices to eliminate or control hazards necessary for safe permit
space entry operations, and allowing only qualified workers to enter
the permit space;
- ensure that at least one attendant is stationed
outside the permit space for the duration of entry operations;
- implement appropriate procedures for summoning
rescue and emergency services, and preventing unauthorized personnel
from attempting rescue;
- establish, in writing, and implement a system
for the preparation, issue, use and cancellation of entry permits;
- review established entry operations annually and
revise the permit space entry program as necessary.3
For a complete list of requirements for written permit-required confined
space programs, see 29 CFR 1910.146.4
Additional recommendations regarding safe work practices in confined
spaces can be found in the NIOSH Publication No. 80-106, Criteria
for a Recommended Standard: Working in Confined Spaces;5
NIOSH Alert Publication 86-110, Request for Assistance in Preventing
Occupational Fatalities in Confined Spaces;6
NIOSH Publication No. 87-113, A Guide to Safety in Confined Spaces;7
and NIOSH Publication No. 94-103, Worker Deaths in Confined Spaces:
A Summary of NIOSH Surveillance and Investigative Findings.8
These publications may be useful in developing confined space safety programs
and in training workers to identify hazards found in confined spaces.
Specific information provided in these publications includes recommendations
for control of hazardous energy, communication procedures, entry and rescue
procedures, posted warning signs, and required safety equipment and clothing.
NIOSH publications are available through the NIOSH web site at http://www.cdc.gov/niosh/
or by calling 1-800-356-4674.
Recommendation #4: Employers should establish work policies that comply
with employment standards for youth less than 18 years of age in nonagricultural
employment. Employers should communicate these work policies to all employees.
Discussion: At the time the victim was hired, his mother presented the
employer with a birth certificate that indicated the victim was 17 years
old. For this reason, it may have been very difficult for the employer
to ascertain the victim’s correct age. However, employers should
make every effort to ensure they are aware of a worker’s true age
and that 14-and 15-year-old workers are not assigned to perform prohibited
work. These requirements are published in Subpart C of Part 570 of Title
29 of the Code of Federal Regulations, Child Labor Regulation No. 3.
Employers who have a multi-lingual/multi-cultural work force should use
interpreters when necessary to inform all employees about age-appropriate
work assignments. If employers do not fully understand the types of work
prohibited for young workers, they should contact the U.S. Department
of Labor (DOL), Employment Standards Administration (ESA), Wage and Hour
Division. This Division enforces child labor laws under the Fair Labor
Standards Act (FLSA).
Under FLSA standards for 14-and 15-year-olds in nonagricultural employment,
employment of 14-and 15-year-olds is limited to certain occupations and
under certain conditions that do not interfere with their schooling, health
or well-being. For example, the victim was working on a Tuesday, during
what would have been school hours. Fourteen and 15-year-olds are prohibited
under FLSA standards from being employed in any occupation where they
might operate, tend, or assist in the operation of power-driven equipment.
Additionally, the FLSA provides a minimum age of 18 years for non-agricultural
work which the Secretary of Labor declares to be particularly hazardous
(Hazardous Orders). Information regarding FLSA can be obtained by visiting
the DOL ESA web site at http://www.dol.gov/esa/.
FLSA employment standards for nonagricultural occupations are listed and
explained in Child Labor Bulletin 1019
and summarized in DOL Fact Sheet No. 43.10
Child labor information can also be obtained by calling or visiting offices
of Federal and State child labor departments, located by using the telephone
directory government pages.
Employers should meet with their workforce to communicate the company’s
policies regarding appropriate work assignments for young workers. They
should explain that young workers are at an increased risk for injury
at work and reinforce the importance of assigning youths to appropriate
work tasks. They should provide all staff with a description of youth
work assignments, identify the person(s) responsible for supervision of
young workers, inform all staff about assigned supervisors, and direct
staff to notify supervisors immediately if they see young workers performing
hazardous work or working outside their assigned tasks.
Recommendation #5: Employers should ensure that machinery is operated
in accordance with manufacturers’ specifications.
Discussion: The bark blower consisted of a hopper, an auger/agitator,
a drag conveyor, a hydraulic system, and electrical energy provided to
the controls. The owner’s manual stated that before performing work
inside the hopper the truck and power box key should be removed, the battery
cables disconnected, the engine operating area should be tagged to show
the equipment was being serviced, and to use lockout/tagout procedures
to isolate all other hazardous energy sources. Anyone entering the hopper
should be trained in these procedures. The mechanic stated during MOSH
interviews that he only removed the key from the box supplying power to
the bark blower and kept it with him. To ensure the safety of workers,
manufacturers’ procedures should be strictly followed.
Recommendation #6: Employers should implement training programs targeted
at youth workers which emphasize the link between unsafe behavior and
the potential for injury and provide constant supervision to younger workers.
Discussion: The victim had received video training on the operation of
the bark blower. The victim had also had training to familiarize him with
the company’s unwritten safety rules and the safe work procedures
he would be required to follow. This training was documented. Both the
training video and the company safety rules stated that the top of the
bark blower hopper was never to be accessed when the bark blower was running.
Company policy stated that only the two qualified company mechanics were
permitted to access the inside of the bark blower bed. While the training
the victim received informed the victim how to perform his job in a safe
manner, it did not explain to the victim the consequences he might face
if the correct procedures were not followed. Training should be structured
so that it identifies the dangers and injuries workers would be exposed
to if they should fail to adhere to safe work procedures. This is especially
important for younger, more inexperienced workers. Additionally, young,
inexperienced workers should be provided constant supervision by a competent
persona when working around hazardous equipment.
Whenever possible, visual contact should be maintained between supervisory
personnel and young workers. Resources for training young workers can
be found in a NIOSH Alert: Preventing Deaths, Injuries and Illnesses
of Young Workers11 available through
the NIOSH web site at http://www.cdc.gov/niosh/
or by calling 1-800-356-4674.
Recommendation #7: Employers should ensure that restroom facilities or
transportation to restroom facilities are available for mobile work crews.
Discussion: 29 CFR 1910.141(c)(1)(ii)12
requires that unless restroom facilities are readily available, mobile
crews should have transportation immediately available to nearby toilet
facilities.In this instance, the crew drove to the incident in the truck
on which the bark blower was mounted. There were no facilities available
at the site. During OSHA interviews, the foreman working with the victim
stated that if no restroom facilities were available, members of his crew
would enter the hopper and use it as a restroom facility. The only way
to travel to restroom facilities was to stop the job completely and take
the truck. Employers should make provisions for access to restroom facilities
prior to the start of any job.
Additionally:
Manufacturers should consider and evaluate the installation of grid-shaped
guards at the top of bark thrower hoppers and over the auger and drag
conveyor during the manufacturing process. Ladder locks to prevent unqualified
workers from accessing the top of the hopper should also be evaluated
and installed if feasible.
Discussion: In this incident, the victim entered the wide-open hopper
of the bark blower. Manufacturers of the bark blower should consider evaluating
some sort of grid-shaped guard system that could be incorporated into
the design at the top of the bark blower hopper and over the rotating
auger and drag conveyor. This system should be designed to allow for the
free flow of mulch while the bark blower was being loaded and would prevent
inadvertent entrance into the hopper of the bark blower and contact with
the auger. The design of the grid system could include a door equipped
with a locking device that would allow for entrance for maintenance operations.
An interlock system that would automatically shut down the blower system,
auger, and drag conveyor if the grid-shaped guard were opened would provide
a redundant and more effective safety feature. At the time of the investigation,
the manufacturer did not offer any type of guarding system for the top
of the hopper or the auger/agitator and conveyor. Additionally, fixed
ladders on the bark thrower blower should be equipped with locking devices
that would block the ladders and prevent unqualified workers from accessing
the top of the hopper.
Manufacturers should consider affixing dual language labels with graphics
to provide hazard warnings and instructions for safe use of equipment.
Discussion: Having employees who speak limited or no English presents
unique challenges. It is important for Spanish-speaking employees to be
able to interpret instruction and warning labels on work equipment such
as the bark blower hopper in this incident. While some equipment is bought
or shipped with manufacturers’ documentation in at least one language
other than English, many instruction and warning labels on the equipment
are only in English. The machine had labels affixed to the hopper detailing
the operating instructions of the machine and the entanglement hazard
inside the hopper; however these labels were in English (Photo
3). A dual language label with a graphic or picture label could offer
an additional warning to workers of potential hazards.
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Photo 3. Safety label (in English) warning
of the entanglement hazard inside the hopper.
Photo courtesy of MOSH |
a A competent person is one who is capable of identifying existing and predictable
hazards in the surroundings or working conditions which are unsanitary,
hazardous, or dangerous to employees, and who has the authority to take
prompt corrective measures to eliminate them.
References
- Code of Federal Regulations [2004]. 29 CFR 1926.21(b)(2). Safety Training
and Education. Washington, DC: U.S. Printing Office, Office of the Federal
Register.
- OSHA [2005]. Hispanic Outreach Module. Accessed October 3, 2005 at
http://www.osha.gov/dcsp/compliance_assistance/index_hispanic.html
- OSHA [2004]. Permit-required confined spaces. Occupational Safety
and Health Administration (OSHA) Publication No. 3138-01R 2004.
- Code of Federal Regulations [2004]. 29 CFR 1910.146. Permit-required
confined spaces. Washington DC: U.S. Government Printing Office, Office
of the Federal Register.
- NIOSH [1979]. Criteria
for a recommended standard: Working in confined spaces. Cincinnati,
OH: U.S. Department of Health, Education, and Welfare, Public Health
Service, Centers for Disease Control, National Institute for Occupational
Safety and Health, DHEW (NIOSH) Publication No. 80-106.
- NIOSH [1986]. NIOSH Alert: Request
for assistance in preventing occupational fatalities in confined spaces.
Cincinnati, OH: U.S. Department of Health and Human Services, Public
Health Service, Centers for Disease Control, National Institute for
Occupational Safety and Health, DHHS (NIOSH) Publication No. 86-110.
- NIOSH [1987]. A
guide to safety in confined spaces. Cincinnati, OH: U.S. Department
of Health and Human Services, Public Health Service, Centers for Disease
Control, National Institute for Occupational Safety and Health, DHHS
(NIOSH) Publication No. 87-113.
- NIOSH [1994]. Worker
deaths in confined spaces: A summary of NIOSH surveillance and investigative
findings. 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. 94-103.
- DOL (U.S. Department of Labor) [2001]. Child labor requirements in
nonagricultural occupations under the Fair Labor Standards Act. Washington
DC: U.S. Department of Labor, Employment Standards Administration, Wage
and Hour Division, WH-1330. Child Labor Bulletin No.101.
- DOL [2002]. Fact Sheet No. 43: Child labor provisions of the Fair
Labor Standards Act (FLSA) for nonagricultural occupations. Accessed
April 7, 2005 at http://www.dol.gov/esa/whd/regs/compliance/whdfs43.htm (Link updated 09/10/2008).
- NIOSH [2003]. NIOSH Alert: Preventing
deaths, injuries, and illnesses of young workers. 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. 2003-128.
- Code of Federal Regulations [2005]. 29 CFR 1910.141 (c) (1) (ii).
Washington, D.C.: U.S. Printing Office, Office of the Federal Register.
Investigator Information
This investigation was conducted by Virgil Casini, Senior Investigator,
Fatality Investigations Team, Surveillance and Field Investigations Branch,
Division of Safety Research.
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