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
192-114-01
Farm
irrigators set up and take apart pipes that carry water to
fields. An irrigator was taking apart a sprinkler system in
a cotton field. His line of sprinkler pipes was connected
at one end to the main water line. This connection was made
by a valve screwed down on the water line, and a ring clamped
over the valve and line.
Just
before taking apart the sprinkler system, water was flowing
in the main water line into the irrigator's line of sprinkler
pipe. To shut off the water to his sprinkler line, the irrigator
bent over the connecting valve and began turning its faucet
handle. The valve cap on top of the connecting valve came
loose. Water pressure from the main water line fired the valve
cap into the worker's face. This broke the worker's jaw, knocked
out his front teeth, and gave him a concussion. Headaches,
dizziness and blurred vision bothered him for weeks after
the injury.
How
could this injury have been prevented?
- Turn
the water off at the main water line, not at the hookup
between the main line and the sprinkler pipe.
- Check
equipment before using it, including the screw threads and
clamps of connecting valves.
- Train
workers in safe work methods. This farm did not have a written
outline for safety training.
BACKGROUND
On May
29, 1992, NURSE staff received a written report of an agricultural
injury from a local medical clinic. The clinic had treated
a 27 year-old Hispanic male irrigator for head and facial
injuries. The incident occurred on May 27, 1992 in a cotton
field watered by a pipeline sprinkler system. The irrigator's
job was to move the sprinkler system pipes into the field,
assemble them and connect the pipes to the main water line.
While the worker was turning off a valve in the sprinkler
system, water pressure blew the cap of the valve into his
face.
A nurse
from the NURSE Project discussed the incident with the injured
irrigator on June 12, 1992. The Senior Safety Engineer from
the NURSE Project discussed the incident with the farm owner
and the two irrigation foremen at their farm office on July
10, 1992. The pipeline sprinkler system had been dismantled
and moved soon after the incident, so the NURSE engineer was
unable to inspect it. NURSE staff also reviewed the employer's
investigation report and the worker's medical records.
The
California Occupational Safety and Health Administration (Cal/OSHA)
was not notified and did not investigate the incident.
The
incident occurred at a family owned and operated cotton farm.
The farm has 12 full-time employees and 25 casual (1-12 weeks
per year) employees. The injured irrigator was hired as a
casual employee and had been on the job for five days. He
had worked as an irrigator on other farms. The Senior Safety
Engineer reviewed the farm's written safety program and noted
it did not address all components required by Title 8 California
Code of Regulations 3203 -- Injury and Illness Prevention
Program. (As of July 1, 1991 the State of California requires
all employers to have a written seven point injury prevention
program: designated safety person responsible for implementing
the program; mode for ensuring employee compliance; hazard
communication; hazard evaluation through periodic inspections;
injury investigation procedures; intervention process for
correcting hazards; and a health and safety program.)
One
component that the safety program did not cover in sufficient
detail was safety training. On this farm, it is the field
foremen's responsibility to give safety talks to workers.
At the time of the NURSE investigation, the field foremen
did not have a written outline to use when reviewing safety
procedures with workers. The farm's written safety materials
were in English, and the field foremen verbally translated
the safety information into Spanish for the employees.
Also,
on this farm, on-the-job training consists of the irrigation
foremen observing the irrigators for the first few days on
the job. An annual safety training program is conducted for
the farm by its workers compensation insurance company. The
insurance company also reviews the farm's safety program each
year and discusses job safety issues with the foremen and
the 12 full-time field workers.
INCIDENT
At approximately
8:00 a.m., on May 27, 1992, a 27 year- old Hispanic male irrigator
was taking apart a sprinkler irrigation system in a cotton
field. This sprinkler system consisted of long sections of
pipe, 20-30 feet in length, connected by clamps. These pipes
are then connected by a valve assembly (see figure) to an
8-inch water line. Water flows from the water line into the
sprinkler pipe at pressures of 55-60 pounds per square inch.
The water is turned off by a lever on the cap of the valve
which is screwed onto the sprinkler pipe, and then clamped
on the pipe with a "snap ring," a ring which tightens and
clamps the pipe to another pipe when it is snapped closed.
Before
he took the pipeline apart and moved the sections to another
place in the field, the irrigator turned the lever on the
valve cap to shut off the water to the sprinkler pipeline.
While the irrigator was bending over the valve assembly, with
his face 1-2 feet away, water pressure forced the valve cap
off and blew it into his face.
It is
not clear why the valve cap came loose. The valve cap may
not have been securely screwed onto the sprinkler pipe, or
the snap ring may not have been securely clamped. When the
irrigator attempted to screw the valve closed, the turning
action may have loosened the valve cap, and then water pressure
forced it off. It is also possible that some part of the valve
assembly failed. If the screw threads holding the valve cap
on the pipe were damaged, or the snap ring clamping the valve
cap to the pipe was broken, the water pressure could have
forced off the valve cap.
Another
irrigator closing valves on a different section of pipe in
the field heard the injured irrigator cry out and came to
his assistance. This co-worker ran to the road and flagged
down the irrigation foreman. The foreman had the injured irrigator
lie down in the cab of his pickup truck, and drove him to
the local medical clinic about 10 miles from the farm. The
injured irrigator was treated at the medical clinic at approximately
8:45 a.m. He had bruises on his face, a concussion, a deep
cut on his right cheek, a broken upper jaw, and his top front
row of teeth were broken off at the base. Doctors at the clinic
gave him pain medication, a tetanus shot, and stitched the
cut on his cheek. They then immediately sent him to an oral
surgeon for treatment of his broken jaw and teeth.
At the
time of the NURSE interview on June 12, 1992, the irrigator
was still receiving follow-up care from an oral surgeon. He
was still complaining of dizziness, blurred vision and headaches.
He is expected to remain on medical disability until the end
of the summer.
PREVENTION STRATEGIES
- The
employer should establish a standard operating procedure
for the safe performance of each task. The procedure should
require irrigators to turn off the water flow to the main
water line before closing the valves on the sprinkler lines
and moving the pipes. (The irrigator noted that this had
been the procedure at the farms where he had worked before.)
If the standard operating procedure on this farm had been
to turn off the water flow at its source, the irrigator
would not have been working on a sprinkler system under
high water pressure. Even if the valve cap had not been
securely fastened, water pressure could not have forced
it off, and the irrigator would not have been injured.
- The
employer should have a comprehensive written injury prevention
program*. Workers should be trained to recognize and avoid
hazards associated with specific tasks. Foremen should be
given a detailed written outline of topics to cover in a
safety training session, and the training materials should
be written both in English and the language used by the
foremen and workers. In this incident, the nature and extent
of the safety training the worker received are not clear.
If the irrigator had been trained in safe methods to take
apart the sprinkler lines, he would not have worked on a
system under high water pressure and would not have been
injured. *Title 8 California Code of Regulations 3203 --
Injury and Illness Prevention Program.
- The
irrigation foreman or a designated safety person should
check all equipment before use. Every time a sprinkler system
is assembled it should be checked before turning on the
water line. All snap rings for valves should be checked
to see if they are missing, rusty, or damaged. If they are,
they should be replaced. Valves should be checked before
use, and faulty valves repaired or replaced. The entire
valve assembly should be checked for any dirt or debris
that might block the connection. If the irrigation foreman
or other designated person had checked the sprinkler system
before use, a faulty valve or snap ring might have been
found and replaced. If the valve had functioned correctly,
then the irrigator would not have been injured.
- 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)**.
In this incident, if the foreman had been trained in proper
response to an injury, he would have called 911 and then
administered first aid until trained EMS personnel evaluated
and provided further treatment for the injured worker's
condition. This might have reduced the risk of complications
from the injury. ** 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."
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-92-005-17
,
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: October 1992.
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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