Fatality Assessment and Control Evaluation (FACE) Program |
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Hispanic Carpenter Dies After Being Crushed Between the Loader Bucket of a Backhoe/Loader and a Concrete Building - North Carolina |
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SummaryOn January 6, 2003, a 25-year-old male Hispanic carpenter (the victim) died after being crushed between the loader bucket of a backhoe/loader and a concrete building. The victim was part of a three-man crew assigned to cover a window with plywood. The victim and a coworker climbed into the loader bucket of the backhoe/loader with the plywood. After the loader bucket was raised to the window, the backhoe/loader operator noticed that one of his coworkers was losing grip on the plywood. The operator, who had placed the loader bucket controls into neutral, jumped off the backhoe/loader to assist. As he jumped, the strap of his fall protection harness, worn as required by company policy, became entangled on the loader bucket control lever, moving it to the dumping position. When the bucket tilted forward, one coworker jumped off the bucket unharmed; the victim, who remained in the bucket, was pinned and crushed against the building. The backhoe operator reversed the backhoe/loader to free the victim. Emergency Medical Services (EMS) personnel arrived within 5 minutes of the 911 call and transported the victim to a local hospital emergency room where he was pronounced dead. NIOSH investigators concluded that, to help prevent similar occurrences, employers should:
IntroductionOn January 6, 2003, a 25-year-old Hispanic carpenter (the victim) died after being crushed between the loader bucket of a backhoe/loader and a concrete building. On January 7, 2003, officials of 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 February 5, 2003, a DSR safety and occupational health team investigated the incident. The NCOSHA compliance officer assigned to the case was present throughout the investigation. The DSR team reviewed the incident with the company site superintendent, one of the vice presidents, and the two Hispanic workers who had been involved in the incident. Another worker who spoke both English and Spanish also attended the interviews as an interpreter. During an on-site visit, photographs of both the incident site and the equipment involved in the incident were taken. Police reports were also reviewed. The official cause of death was obtained from the medical examiner via telephone. The victim’s employer was a general contractor that had been in business since March 1985. The company employed 500 full-time employees. Twenty-two employees had been working at the incident site for 16 months building a multi-unit residential complex, which was expected to be completed in July 2003. The work shift generally started at 7:30 a.m. and ended at approximately 4 p.m. daily. The victim, an emigrant from Mexico, had worked on this construction site as a subcontractor for a few months before being hired by his present employer as a carpenter 6 months before the incident. The victim and his two coworkers, who had known each other prior to the victim’s joining the company, primarily spoke Spanish. They spoke very little English. The site superintendent in charge of this project only spoke English. The company had a written safety program that was adapted from a major safety and health publishing company. The safety program was written in both English and Spanish. Safety meetings were held weekly and information was communicated in both English and Spanish. Topics such as fall prevention, hazard communication, excavations and trenches, and electrical power were covered in these meetings. The topic of potential hazards associated with using a backhoe/loader had not been a subject for these talks. Backhoe/loader operator training had been provided on the job by an employee who was able to read and speak both English and Spanish. The training was focused on showing employees how to operate a backhoe/loader to complete tasks. The training had not been documented, and there were no requirements for evaluation of employees’ competency after completing the training. The backhoe/loader operator in this incident, whose job title was carpenter’s helper, had operated the company’s backhoe/loader with an experienced employee on the scene 1 hour per week for about 4 weeks before the incident. He never operated a backhoe/loader independently before the day of the incident. Up until this incident, the company had not had any workplace fatalities. Back to TopInvestigationThe scene of the incident was a newly constructed, multi-unit residential complex that included a nine-story building complex with three levels of underground parking. This particular building integrated residential, commercial and parking facilities. The project was to be completed over a 22-month period. At the time of incident, construction debris was being removed through a chute (Photo 1), which was on the east side of the building. The victim and two coworkers were assigned to cover the window (Photo 2) under the chute with plywood to avoid window damage when debris passed through the chute.
On the day of the incident, the workday began with a 7 a.m. safety meeting; its topic was not specifically related to the work assignment of that day. At approximately 7:30 a.m., the window crew was sent to install the window cover. When the men arrived at the site where plywood sheets were stored, they discovered that the plywood sheets were wet, making them too heavy to carry. They decided to use a backhoe/loader (Photo 3) to transport the plywood sheets. One of the men (referred to as the backhoe operator) got the key to the backhoe/loader from an employee who was temporarily assigned to keep the heavy equipment keys.
The employee normally responsible for issuing these keys was absent from work that day. The operator drove the backhoe/loader loaded with plywood sheets to the work site. The crew then screwed two plywood sheets together and cut it to the window size. The plywood could then be wedged into the window frame, requiring no nailing that may have damaged the concrete. The window to be covered was about 4 to 5 feet above ground level. The victim and his coworkers decided to use the loader bucket (which measured approximately 7 feet wide by 4 feet high by 3 feet deep) of the backhoe/loader to reach the window. Generally, either a ladder or a boom-supported aerial platform (Photo 4) would have been used. According to the workers involved in the incident, a ladder was not used that day because the wet plywood sheets were too heavy to be lifted manually. A boom-supported aerial platform was on site, but it was not used because the equipment would have blocked a traffic lane. According to the statements of the two coworkers during the OSHA interview, the crew was unaware that traffic had been diverted so that equipment could be parked in the traffic lane.
Around 9:30 a.m. after the morning break, the victim and a coworker climbed into the loader bucket of the backhoe/loader with the cut-to-size plywood. The bucket was elevated to approximately 3 feet above ground level, and then the loader bucket controls were placed in a neutral position. The victim and one coworker were standing in the bucket holding the plywood. When the backhoe operator saw one of his coworkers (not the victim) struggling to maintain a grip on the plywood, the operator attempted to get out of the backhoe/loader to help. As he exited the backhoe/loader cab to the right, the strap of his body harness, which was mandated by the company’s safety policy to be worn at all times for fall protection, was caught on the loader bucket control lever (Photo 5), located to the right of the driver’s seat, pulling it to the right. This caused the bucket to tilt forward into a dumping position. The victim’s coworker jumped out the bucket uninjured. The victim, who held onto the plywood, was pinned and crushed between the loader bucket and the concrete building. The coworker, who had jumped clear, ran to the office for help. After the backhoe operator took off his body harness to free himself, he reentered the backhoe/loader cab and backed up approximately 2 to 3 feet to free the victim. The victim dropped to the ground. The operator then exited the cab to the left and ran to assist the victim. By the time EMS and police personnel responded, approximately within 5 minutes, the victim had lost consciousness. EMS immediately transported the victim to a local hospital emergency room where he was pronounced dead. At the time of the incident the site superintendent was working inside the building and did not witness the incident.
The backhoe/loader used in the incident (Photo 3) was owned by the company. The site superintendent indicated that he had no knowledge that the loader bucket of the backhoe/loader had ever been used to lift or transport people prior to the incident. When the equipment inspectors from the company and the manufacturer examined the backhoe/loader involved in the incident, they did not find any evidence of malfunction. According to the NCOSHA report, an EMI (Equipment Manufacturers Institute) booklet, written in English and used for training, was found in the backhoe/loader, but the operator’s manual from the manufacturer was not. Back to TopCause of DeathThe medical examiner’s report indicated that the death resulted from blunt force injuries of the chest, abdomen and pelvis. Recommendations/DiscussionRecommendation #1: Employers should develop, implement and enforce a written policy which requires the use of specified types of working platforms for elevated tasks.Discussion: Elevated work tasks have been associated with many occupational hazards including risk from falls.1 To help reduce this risk, equipment specifically designed for working at heights should always be used for elevated tasks. Having an enforced written policy to require the use of specified types of working platforms for elevated tasks could help eliminate or reduce risks from falls and other hazards.
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