Oregon Case Report: 03-OR-029-01 |
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Summary
On September 6, 2003, a 75-year-old logger, working as a bulldozer operator,
was killed when the D6H Caterpillar crawler tractor he was operating tumbled
off a steep skid road into a ravine. The operator was climbing a 20-25
degree slope while reopening an old skid road. The bulldozer slid off
of the road against a tree while on a hard rock face covered by a 4-inch
surface of scrabble rock. The operator apparently regained control, and
may have been trying to get the bulldozer back up on the road when it
slipped off the 60-70 degree sidehill and tumbled about 150 ft to a logging
road, where the operator was ejected. The bulldozer bounced another 450
ft into a ravine. The event was not witnessed. Fatal injuries probably
occurred when the victim was thrown around in the cab, before being ejected.
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The D6H Caterpillar following
the incident shows noticeable damage – missing the front blade,
rear grapple, and tracks – but the operator’s cage is
relatively intact. |
Recommendations:
- Develop a site-specific safety plan that includes an assessment of
hazards and plans to minimize the risks.
- When operating off-road work machines, wear the seatbelt, or utilize
some other form of personal safety restraint.
- Seek assistance when needed.
- Drop the blade to help control or stop a slide.
- Manufacturers should evaluate operator restraint systems for mobile
equipment to design improvements that facilitate use of seatbelts and
harnesses.
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Introduction
On September 6, 2003, a 75-year-old logger, working as a bulldozer operator,
was killed when the D6H Caterpillar crawler tractor he was operating tumbled
off a steep skid road into a ravine. OR-FACE was notified of the incident
on September 8. An OR-FACE investigator conducted an onsite visit with
the employer the next day. This report is based on the OR-FACE investigation,
and reports from Oregon OSHA, the county sheriff, and medical examiner.
The logging firm had been in business for approximately 60 years. The
current management operated the business for the past 16 years, and employed
three full crews, about 20 workers, down from a peak workforce of 120
in earlier years. Six workers were in the area at the time of the incident.
The employer had a written safety program and held weekly safety meetings
with all of the crews. In addition, a logging safety consultant regularly
visited all sites, unannounced, and observed employees while working.
The consultant met with individuals in one-on-one sessions and in full
work teams to discuss safety performance.
The bulldozer operator was a partner in the original business and had
since retired, but helped out from time to time. With over 50 years of
experience, he was a longstanding member of the local logging community
and very knowledgeable in all aspects of logging. He was skilled in operating
all kinds of logging machinery, and trained the current employer. This
special relationship prevented the employer from enforcing certain safety
standards that applied to other employees, such as wearing a seat belt
while operating the bulldozer.
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Investigation
The logging firm was working on private land in a salvage operation.
A large forest fire burned the area in 2002, and the operator had been
harvesting dead, burned standing timber in the unit for more than a year.
The unit was properly designated as an active logging area, but the old,
disused roads needed to be improved before beginning logging operations.
Even with improvements, the roads were only “minimal,” according
to the employer. The terrain ranged from gradual 15-20 degree slopes to
very steep.
On the day of the incident the bulldozer operator was working to reopen
a pre-existing skid road. The road was cut into the hillside, rising at
a 20-25 degree slope from the main logging road toward the top of the
unit. The operator had taken the bulldozer down the road a few days before
and was familiar with the road’s general layout.
About 150 ft up the road, a hard layer of sedimentary rock was exposed.
The bulldozer’s metal tracks lost traction on the slick rock surface,
and the 27-ton machine slid off the road, but was stopped by an old madrone
tree. The bulldozer was facing uphill at this point. The operator had
probably dropped the blade in an attempt to stop the slide off the road,
causing the machine to face uphill when it came to rest against the tree.
The operator regained control and apparently decided to turn downhill
to get off the side of the mountain.
The exact maneuver at this point is not clear, but in the effort to regain
the road, the bulldozer slipped off the steep 60-70 degree sidehill and
tumbled several times before hitting the main logging road 150 ft below.
The impact tore off the blade and the operator was ejected. The bulldozer
continued to tumble to the bottom of the ravine another 450 ft farther,
leaving a trail of metal debris.
The victim was found sitting up, supported by a stump about 50 ft below
the main road. He was pronounced dead at the scene. It is believed the
victim died from injuries received while being thrown around inside the
cab.
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Arrows indicate the path
of the Caterpillar as it tumbled off the skid road into the ravine.
The star shows where the operator was thrown from the cab.
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Cause of Death
Multiple traumatic injuries.
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Recommendations/Discussion
Recommendation #1: Develop a site-specific safety plan that includes
an assessment of hazards and plans to minimize the risks.
Before starting logging operations and site development, a work plan
should be developed beforehand that includes a survey of site hazards.
The survey should evaluate all potential work areas for hazards, and specify
procedures to eliminate or minimize risks. The plan needs to be conveyed
to all employees working at the site at a pre-work safety meeting.
Recommendation #2. When operating off-road work machines, wear the seatbelt,
or utilize some other form of personal safety restraint.
The victim in this incident is reported to have rarely worn personal
restraints while operating heavy equipment. The employer acknowledged
this was a risky work practice, but also believed the personal restraints
were not designed to meet the demands of the working conditions where
the bulldozer was being used. Employees operating heavy equipment with
this employer have complained about using personal restraint systems,
because they are often bruised or injured by them, even in less demanding
circumstances.
In the development of the OSHA standard requiring the provision and use
of seatbelts in mobile logging machinery (29 CFR 1910.266 (d)(3)), consideration
was given to received comments regarding undue restriction and increased
hazard on steep terrain. Reviewing the evidence of machine rollovers,
however, showed that all victims were thrown from the cab and crushed
by the machine, which might have been avoided by providing and wearing
a seatbelt. OSHA considered, but decided not to allow any exceptions to
the seatbelt rule. Due to evidence that many operators wear the seatbelt
loosely, and that this does not protect the operator in a rollover, OSHA
also requires the seatbelt to be securely fastened.
Recommendation #3. Seek assistance when needed.
The operator in this incident could have sought assistance when he first
slid off of the road. Even an experienced operator should be willing to
acknowledge hazardous circumstances and solicit help and advice from coworkers.
Recommendation #4. Drop the blade to help control or stop a slide.
When faced with a situation where the bulldozer starts to slide, it is
best to drop the blade in an attempt to stop the downward progression.
Usually dropping the blade is enough to stop sideways motion, though in
some circumstances the blade may slide on the hard surface as well. On
steep terrain, wherever possible, a bulldozer should face downhill while
working to increase the effectiveness of the blade to control a slide.
Recommendation # 5. Manufacturers should evaluate operator restraint systems
for mobile equipment to design improvements that facilitate use of seatbelts
and harnesses.
To encourage operators to wear a seatbelt, better design and different
options need to be made available to improve usability. Even in simple
circumstances, mobile equipment operators must continually move around
in the seat for visibility. Worker dissatisfaction with the present design
of occupant restraints in heavy equipment leads to noncompliance and management
enforcement issues. Improved seatbelt designs that keep operators restrained
within the cab in the event of a rollover or tipover, while at the same
time providing them with comfort and maximum mobility within the cab are
needed (see OSHA 1996 for further discussion of this issue).
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References
- National Institute for Occupational Safety and Health. (2004). Preventing
injuries when working with ride-on roller/compactors [Pub 2005-101].
Available online: http://www.cdc.gov/niosh/docs/wp-solutions/2005-101/pdfs/2005-101.pdf
- Occupational Safety & Health Administration. (1996). Logging operations:
Paragraph (d) General requirements: Seat belts [29 CFR 1910.266]. Available
online: http://www.osha.gov/SLTC/etools/logging/sections/preamble/seatbelts_preamble.html
- West Virginia Fatality Assessment and Control Evaluation. (2003).
Logging site heavy equipment operator dies after being pinned by the
dozer he was operating in West Virginia [03WV022-01]. Available online:
http://www.cdc.gov/niosh/face/stateface/wv/03wv022.html
Oregon FACE Program
CROET at OHSU performs OR-FACE investigations through a cooperative agreement
with the National Institute for Occupational Safety and Health (NIOSH),
Division of Safety Research. The goal of these evaluations is to prevent
fatal work injuries in the future by studying the work environment, the
worker, the task, the tools, the fatal energy exchange, and the role of
management in controlling how these factors interact.
To contact Oregon
State FACE program personnel regarding State-based FACE reports, please
use information listed on the Contact Sheet on the NIOSH FACE web site.
Please contact In-house
FACE program personnel regarding In-house FACE reports and to gain
assistance when State-FACE program personnel cannot be reached.
Oregon FACE reports are for information, research, or occupational injury
control only. Safety and health practices may have changed since the investigation
was conducted and the report was completed. Persons needing regulatory
compliance information should consult the appropriate regulatory agency.
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