Fatality Assessment and Control Evaluation (FACE) Program |
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Metal Fabrication Shop Owner Dies When Crushed By Falling Steel Plate |
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SummaryOn December 15, 2003, a metal fabrication shop owner died when a 4,000 pound steel base plate fell on him. While inside the shop building, the work crew of least three men, including the owner, fabricated a 10’x 20’ steel base plate to be used at a water treatment plant. The base plate was to house or serve as a base anchor a large water pump. After welding connectors and channel iron beams to one side of the plate, the crew pushed the plate through a bay door with a forktruck to an outside area in back of the shop. The forktruck operator used the forks to lift one side of the plate. The owner then crawled headfirst underneath the plate to place blocks underneath the plate. While the owner was underneath the plate, the plate slipped off the forks of the forktruck, and the plate fell on the victim. He died at the scene due to multiple blunt force injuries. To prevent occurrences of similar incidents, the following recommendations have been made:
BackgroundOn February 27, 2004, the Kentucky Fatality Assessment Control and Evaluation program became aware of an industrial incident involving a fatality via newspaper surveillance. The coroner was contacted and a site visit was made on March 23, 2004 to the facility. The coroner and the succeeding business owner were interviewed. Photographs were taken of the shop. To get a better perspective of the steel fabrication industry, another steel fabrication shop owner with over 20 years of experience and a buyer with 10 years of experience were also interviewed for this report. The victim in this incident owned a metal fabrication business that produced steel plate bases for large motors and pumps. Bases were made of steel and channel iron. Due to space limitations inside the facility, it was common practice to push the large plates outside with a fork truck, flip them over, then push the plates back inside so the other side could be worked on. This procedure was used when pieces required welding or painting. Three years prior to his death, the victim had purchased the business from a family member who retired. The deceased had worked in the business for the previous owner for several years before purchasing it. Shortly after the victim’s death, the business was sold to another relative. According to the succeeding owner, the decedent performed all of the dangerous tasks himself. Two local students were employed on an as-needed basis and were working the day of the incident. There were no known written safety procedures. Also, there was not a certified competent person employed by the business (including the owner). Employee work hours depended upon contracts and the labor required to meet contract deadlines. Employment records for the laborers which might have included training
records were not According to a weather service, the average high air temperature for the week before the incident was 34.6°F high and the high on the day of the incident was 38°F. There was no precipitation on the day of the incident and the month-to-date precipitation was 0.88 inches. It was unlikely that the ground was slick from ice, snow or water that might have caused the steel plate to shift and fall from the forks of the forktruck. Back to TopInvestigationA small steel fabrication business was contracted to build a base plate for a water pump that would pump tens of thousands of gallons of water per day. When completed, the 10’ x 20’ steelplate would weigh approximately 4,000 pounds. On the day of the incident, the decedent and 2 laborers were fabricating a ½” x 10’ x 20’ steel metal plate weighing approximately 4,000 pounds. One side of the plate base had been completed with channel iron beams and connectors. One of the laborers operated the forktruck and pushed the plate outside the shop so it could be flipped over and pushed back inside to continue work on the other side of the plate. After pushing the plate outside, the forktruck operator slipped the forks under one side of the plate and tilted the plate with the other side on the ground. The owner then crawled headfirst under the plate to place blocks underneath. As he was positioning the blocks under the plate, the plate slipped off the forks and fell on the victim. One of the laborers immediately called emergency services. The incident occurred at approximately 2:52 pm. Emergency services arrived at the scene within minutes of receiving the call. Paramedics arrived, assessed the victim and contacted the coroner at 3:13 pm. The coroner arrived at 3:20 pm and declared the victim dead at the scene at 3:30 pm. Back to TopCause of DeathThe autopsy report stated the victim died due to multiple blunt force injuries. Recommendations and DiscussionRecommendation No. 1: Employers should provide and use adequate procedures
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Back of shop where steel plate fell on business
owner. The crane was used to load and unload materials. |
Base plate inside shop before being pushed
outside to be turned over. This plate is very similar in configuration
to the one which fell on business owner. |
An example of how the fork truck was
used to lift the metal plate. This plate is similar to the one that
fell on the business owner. |
An example of the metal base plate which fell on business owner. |
The Kentucky Fatality Assessment & Control Evaluation Program (FACE) is funded by a grant from the Centers for Disease Control and the National Institute of Safety and Health. The purpose of FACE is to aid in the research and prevention of occupational fatalities by evaluating events leading to, during, and after a work related fatality. Recommendations are made to help employers and employees have a safer work environment.
To contact Kentucky 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.