California Department of Health Services
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of this document is available in english and spanish.
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SUMMARY : CASE
192-012-01
A maintenance
worker in a fruit drying plant was cleaning and oiling a tray
transporter. A tray transporter is a set of rollers which
move trays of fruit across the plant. The rollers are turned
by a chain drive and a rotating shaft. The safe method to
clean and oil this tray transporter is to shut the power off,
lock the power switch, unbolt a guard that shields the rollers,
and work on that side, opposite the chain drive and shaft.
To save
time the worker left the transporter running and did not unbolt
the guard. Instead he climbed under the transporter and worked
on the same side as the rotating shaft. When he leaned over
the rotating shaft to oil the rollers the shaft caught his
jacket sleeve. The shaft pulled his arm in and broke both
bones in his forearm. His partner got to the switch in a few
seconds and turned off the machine.
How
could this injury have been prevented?
- Follow
safety procedures. The plant had a procedure for shutting
off the power and oiling the rollers from the safe side.
- Do
not wear loose clothing when working around machinery.
- Make
sure that company safety procedures are acceptable to workers.
If workers skip safety steps the steps may need to be changed.
- Foremen
should go over safety procedures with workers when they
assign jobs.
BACKGROUND
On February
4, 1992, NURSE staff learned of an agricultural-related injury
while conducting a record review of the emergency department
of a regional trauma center. In this injury a maintenance
worker sustained a broken arm while cleaning and oiling machinery
in a California fruit dehydrating and packaging plant. At
the time of the incident the equipment was undergoing a pre-season
maintenance check and was not being operated. The equipment
transports trays of fruit from the storage bin on a set of
chain driven rollers, dumps the fruit into a holding bin and
then moves the trays back to the loading area. A nurse from
the NURSE project conducted an interview with the injured
worker on February 14, 1992. At this time, the injured worker
stated he had at least seven years of experience doing this
type of work at the plant. The employee also said he had received
safety training for cleaning and maintenance of machinery
at the fruit processing plant. An on-site investigation was
conducted on March 13, 1992 by the Senior Safety Engineer
and the nurse. The incident was discussed with the vice president
of the company who handles personnel and is also the company
safety director. The local Cal/OSHA compliance office was
notified by the employer. Because the employee was treated
in the emergency department and not admitted to the hospital
for treatment, the Cal/OSHA compliance office did not visit
the job-site or investigate the incident.
The
incident occurred in a fruit processing plant in a rural area,
with approximately 163 employees in peak season. Ten workers
are full-time and three are family members who work at the
plant. The employer has an on-going safety program. The company
safety and health program was reviewed by the local OSHA compliance
office the previous year following a complaint generated visit
(the complaint was relative to hazard communication). The
company's Injury Prevention Program was reviewed by the Senior
Safety Engineer from the NURSE project and was found to address
all seven points within California Code of Regulations Title
8 3202. (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 employees compliance; hazard
communication; hazard evaluation through periodic inspections;
injury investigation procedures; intervention process for
correcting hazards; and a health and safety training program.)
The
employer has a safety training program which includes safety
meetings every two weeks. New hires are given safety training
along with their initial work training program. Maintenance
employees work in pairs or a "buddy system" which provides
a safety back-up if there is a problem.
INCIDENT
On January
21, 1992 at approximately 2:50 p.m. a local emergency medical
service (EMS) was called via 911 and notified that a maintenance
worker's right arm had been fractured. At this time the dehydrating
plant's safety director was also notified. The worker was
a 23 year old Hispanic male.
The
injured maintenance worker, one of 10 full-time year around
employees, was cleaning and lubricating the rollers leading
to the tray transporter. The standard operating procedure
was to stop the equipment (by shutting the power off and locking
the power switch), remove a tray barrier guard (which prevents
the trays from falling on the floor as they move down the
line) and service the equipment on the side of the tray transporter
away from its rotating drive shaft. The rolling device which
moves the trays away from the unloading station was left on
and moved at a slow rate. The employee climbed under the structure
which supports the tray transporter and started to lubricate
the rollers from the inside of the equipment stand. As he
leaned over the rotating shaft to oil the rollers the right
sleeve of his jacket was caught in the rotating shaft. He
tried to remove his arm from his jacket but his arm had already
become entangled in the rotating shaft. He immediately called
for his work partner to turn off the machine. His partner
was nearby and able to turn the machine off within a few seconds.
While
awaiting the arrival of the EMS, the safety director arrived
on the scene and had the rotating shaft cut loose from the
machine, but did not attempt to free the worker's arm.
Paramedics
from the EMS and the district fire department arrived 22 minutes
after being contacted. The EMS personnel removed the arm from
the part of the shaft which had been cut loose. They splinted
and applied an ice pack to the arm. Oxygen was administered
and a Lactated Ringers solution IV was started. The injured
worker was then transported to the local emergency department
of the regional trauma center; he arrived there one hour after
the initial 911 telephone contact. The injured worker underwent
a closed reduction of a fracture of the right radius and ulna.
He was kept in the emergency department for observation and
was then discharged later that evening.
PREVENTION STRATEGIES
- Normal
operating procedure called for lock-out of all equipment
prior to servicing. ("Lock-out" involves shutting off the
power to the equipment and padlocking the power switch.)
If the machinery was not powered then the shaft would not
have been rotating and even if the worker's sleeve came
into contact with the shaft it would not have been caught.
If the employee had followed this company policy while servicing
the equipment this injury would not have occurred*. * Title
8 California Code of Regulations 3314. "Machinery or equipment
capable of movement shall be stopped and the power source
de-energized or disengaged...during cleaning, servicing,
or adjusting operations."
- In
this incident the worker's clothing got caught on the rotating
shaft. If the worker had worn tight-fitting clothing which
could not become caught by machinery this injury might have
been prevented. This is an inexpensive and relatively simple
way of preventing machinery entanglement**. ** Title 8 California
Code of Regulations 3383 (b). "Loose sleeves, tails, ties,
lapels, cuffs, or other loose clothing which can be entangled
in moving machinery shall not be worn."
- The
standard operating procedure for oiling the roller system
is to remove the tray barrier so that the rollers could
be more easily accessed from the side away from the rotating
shaft. To remove the barrier the worker would have had to
unbolt four bolts which would take approximately five minutes;
however, he chose to by-pass this procedure. Therefore,
the worker leaned over the rotating shaft in order to reach
the rollers from the other side. If the worker had followed
standard procedure he would have accessed the rollers from
the correct side and would not have come into contact with
the rotating shaft.
- This
incident points out the importance of ensuring that company
procedure is acceptable to the workers. In this incident,
the worker intentionally chose to by-pass an established
company procedure to save time. This indicates that the
procedure was not acceptable or easily followed. Workers
should be allowed to review and comment on maintenance procedures
for equipment that they service.
- The
foreman should re-enforce the importance of safety procedures
at the work site with the maintenance workers prior to starting
the work day. Emphasis should be on pointing out specific
hazards related to their tasks. This should also include
ensuring employees understand that safety procedures must
be followed to prevent injuries. If this worker had been
instructed earlier that day as to the hazards related to
his specific job tasks for that day, he might not have violated
the standard operating procedures.
- The
company safety policy and training instructed workers not
to wear loose clothing when working around machinery. At
the time of this investigation the safety director noted
that the sleeve of the worker's coat was loose and had become
entangled in the rotating shaft. If the foreman had noted
the worker's loose clothing prior to his entanglement, this
injury would have been prevented.
- In
this incident the worker did not lock-out equipment and
was working in the vicinity of a rotating shaft; these hazards
should be clearly made aware to the worker. One way of notifying
workers about hazards is to use warning signs placed in
the vicinity of the hazard. The employer could post warning
signs in strategic locations near switch boxes and power
sources reminding employees to lock-out power prior to servicing
equipment, and near any mechanical hazards such as the rotating
shaft. Use of signs may help increase worker's awareness
about hazards and how to avoid them. In this incident, if
the worker had seen a sign specifically identifying a hazard
(the rotating shaft) he might not have leaned over it and
come into contact with it.
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-92-005-06,
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: May 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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