Equipment Operator Ran Over by Grader

Transcription

EQUIPMENT OPERATOR RAN OVER BY
GRADER
Type of Incident: FATALITY
Date of Incident: Sept. 19, 2011
File: F-OHS-010481-68AE2
TABLE OF CONTENTS
SECTION
TITLE
PAGE NUMBER
1.0
DATE AND TIME OF INCIDENT
3
2.0
NAME(S) & ADDRESS(ES) OF PRINCIPAL PARTIES
3
2.1
Owner/Contractor
3
2.2
Employer
3
2.6
Worker
3
3.0
DESCRIPTIONS OF PRINCIPAL PARTIES
3
3.1
Owner/Contractor
3
3.3
Employer
3
3.6
Worker
4
4.0
LOCATION OF INCIDENT
4
5.0
EQUIPMENT, MATERIAL AND OBSERVATIONS
4
5.1
Equipment and Material
4
5.2
Observations
4
6.0
NARRATIVE DESCRIPTION OF INCIDENT
6
7.0
ANALYSIS
7
7.1
Direct Cause
7
8.0
FOLLOW-UP/ ACTION TAKEN
8
8.1
Industry
8
9.0
SIGNATURES
8
10.0
ATTACHMENTS
8
Attachment “A” Map
Attachment “B” Diagram
Attachment “C” Photographs
2
Occupational Health and Safety Delivery
Human Services
Date: August 28, 2013
SECTION 1.0
1.1
DATE AND TIME OF INCIDENT
The incident occurred on Sept. 19, 2011 at approximately 8:40 a.m.
SECTION 2.0
NAME AND ADDRESS OF PRINCIPAL PARTIES
2.1
Owner and Contractor
2.1.1
Alberta Ministry of Transportation
P.O. Box 97
Fairview, Alberta
T0H 1L0
2.2
Employer
2.2.1
LaPrairie Works Inc.
Box 479
Hines Creek, Alberta
T0H 2A0
2.3
Worker
2.3.1
Equipment Operator (****** ****)
519-9th Street
Hines Creek, Alberta
T0L 2A0
SECTION 3.0
DESCRIPTION OF PRINCIPAL PARTIES
3.1
The Government of Alberta Ministry of Transportation is responsible for the long-term
planning of the provincial highway networks and oversees the network's design,
construction, and maintenance activities. Since 1966, the Ministry of Transportation has
outsourced highway maintenance to private contractors. LaPrairie Works Inc. was
awarded a contract effective from May 16, 2009 to July 31, 2015 to maintain the
roadways in the north west region of the province (Attachment A, Map 1). The Ministry
of Transportation oversees the work to ensure that is conducted in an efficient manner
and to the conditions specified in the contract.
3.2
LaPrairie Works Inc. is a full service contracting company that specializes in road and
bridge maintenance and construction. In north western Alberta, LaPrairie Works Inc.’s
head office and primary service yard is located in Grimshaw. To provide highway
maintenance services for the north west region, LaPrairie Works Inc. has 19 satellite
service yards including one located in Hines Creek. The LaPrairie Works Inc. Hines
Creek satellite service yard provides the equipment and operators to maintain the
roadways in the vicinity including Secondary Highway 682. The grader and Equipment
3
Human Services
Operator (****** ****) who to maintained Secondary Highway 682 was based out of the
LaPrairie Works Inc. satellite service yard in Hines Creek.
3.3
The Equipment Operator (****** ****) was employed by LaPrairie Works Inc. since
Oct. 1, 2002 as a grader operator. He was based out of the Hines Creek satellite service
yard and Secondary Highway 682 was a regular route maintained by the Equipment
Operator (****** ****).
SECTION 4.0
4.1
LOCATION OF INCIDENT
The incident occurred in the Municipal District of Fairview near the intersection of
Secondary Highway 682 and Range Road 54 (Attachment A, Map 2).
SECTION 5.0
EQUIPMENT, MATERIAL AND OBSERVATIONS
5.1
Equipment and Material
5.1.1
Grader (Attachment A, Photograph #1)
Make: John Deere
Model: 770 D
Equipment Number: G2350
Year: 2009
Serial Number: DW770DX623026
Hour Metre: 5050
The grader was owned and insured by LaPrairie Works Inc. The equipment was
purchased new and had been assigned to the Equipment Operator (****** ****) since
the date of arrival. The grader was equipped with a GPS tracking device that monitored
the grader’s location, time, speed and blade position.
5.1.2
Secondary Highway 682 and Range Road 54
The grading work required on Secondary Highway 682 was located approximately 35
kilometers from the LaPrairie Works Inc. service yard in Hines Creek. Only a portion of
the Secondary Highway 682 road was gravel. The grader was driven off Secondary
Highway 682 and turned north bound onto Range Road 54 (Attachment A, Map 2 & 3).
5.2
Observations
5.2.1
Occupational Health and Safety Investigators arrived at the scene on Sept. 19, 2011 at
2:00 p.m. The scene had been secured by the RCMP.
4
Human Services
5.2.2
The grader was in the ditch along the east side of Range Road 54 (Attachment C,
Photograph #2). The service doors were open on the back end of the grader and the door
to the cab was also open. There was a flashlight, crescent wrench and crowbar found on
the road at the scene (Attachment C, Photograph #3).
5.2.3
Inside the cab of the grader, the gear selector was in 3rd gear forward (Attachment C,
Photograph #4). A pair of coveralls was located on the seat of the grader and a traffic
vest was hung inside the cab. A manufacturer’s warning/caution sticker referring to the
steps to be taken before leaving the operator’s seat was located under the steering wheel
(Attachment C, Photograph #5).
5.2.4
The mobile phone inside the cab of the grader was examined and the last number dialed
was confirmed to be to the LaPrairie Works Inc. Shop Supervisor (***** *******) at
7:26 a.m. on Sept. 19, 2011.
5.2.5
Occupational Health and Safety Investigators retained a journeyman heavy duty
mechanic with ProEx to conduct a field function test of the grader. The field function
test did not reveal any deficiencies with the safe operation of the grader. There were no
issues regarding the gear selection/transmission or the parking brake. The grader was
seized by Occupational Health and Safety Investigators from the scene of the incident on
Sept. 19, 2011. The grader was transported to the ProEx heavy duty shop located in
Grande Prairie.
5.2.6
The grader was further tested and examined by the certified heavy duty mechanic with
ProEx. Although there were no operational deficiencies found with the grader, it was
recommended the transmission shift solenoids be replaced and recalibrated to ensure that
a sticking solenoid valve was not causing an intermittent problem with the transmission
At the time of the testing, there was no condition that could reproduce or induce any
problems with the transmission mechanisms. The grader was released back to LaPrairie
Works Inc. on Nov. 25, 2011.
5.2.7
The grader had a computer service advisor that recorded equipment malfunctions or
warnings. The service advisor history page was examined and there were no recorded
issues that occurred on the day of the incident.
5.2.8
The GPS data was obtained from the grader. The date and time were confirmed to be
accurate. The data showed that the Equipment Operator (****** ****) had not started
grading the road when he called the Shop Supervisor (***** *******) at 7:26 a.m. to
report a mechanical issue with the grader.
5.2.9
The mechanical records were examined and were being completed as required by the
manufacturer. The Equipment Operator’s (****** ****’*) pre-trip inspection reports
were also reviewed. The Equipment Operator (****** ****) filled out the pre-trip
5
Human Services
inspection reports frequently; however there was no pre-trip inspection or notes logged
into the equipment log book on the day of the incident. None of the pre-trip inspection
reports or log book entries that had been completed prior to the incident indicated any
mechanical deficiencies related to the park brake or transmission problems with the
grader.
SECTION 6.0
NARRATIVE DESCRIPTION OF THE INCIDENT
6.1
On Sept. 19, 2011 at 6:50 am the Equipment Operator (****** ****) left the LaPrairie
Works Inc. yard in Hines Creek with the John Deere grader Unit G2350.
6.2
The Equipment Operator (****** ****) drove approximately 35 kilometers to the
eastern graveled portion of Secondary Highway 682 (Attachment A, Map 2). At 7:26
a.m. the Equipment Operator (****** ****) placed a call from the grader mobile phone
to his Shop Supervisor (***** *******).
6.3
The Shop Supervisor (***** *******) indicated the Equipment Operator (****** ****)
told him that he heard a strange sound coming from the back end of the grader. The Shop
Supervisor (***** *******) instructed the Equipment Operator (****** ****) bring the
grader back to the shop in Hines Creek. The Equipment Operator (****** ****) asked
the Shop Supervisor (***** *******) if he should leave the gravel windrow on
Secondary Highway 682. The Shop Supervisor (***** *******) instructed the
Equipment Operator (****** ****) to blade down any gravel windrows he had created
then to drive the grader back to the shop in Hines Creek.
6.4
At 7:27 a.m. the Equipment Operator (****** ****) turned the grader to face west,
lowered the main blade and proceeded to grade Secondary Highway 682 in a west bound
direction (Attachment C, Photograph # 6).
6.5
At 7:56 a.m. the Equipment Operator (****** ****) stopped the grader for 10 minutes,
and then turned the grader back in the opposite direction, facing east. At 8:06 a.m. the
Equipment Operator (****** ****) started grading Secondary Highway 682 in an east
bound direction.
6.6
The Equipment Operator (****** ****) graded Secondary Highway 682 in an east
bound direction for 15 minutes and at 8:21 a.m. he lifted the grader blade and turned the
grader north onto Range Road 54.
6.7
The Equipment Operator (****** ****) moved the grader blade down and the machine
stayed stationary for 6 minutes. At 8:27 a.m. the blade was moved back up and the
machine was inched forward. Between 8:27 am and 8:39 a.m. the grader was reversed
slightly and then moved forward while the blade was up and then remained stationary.
6
Human Services
6.8
Sometime between 8:21 a.m. and 8:41 a.m. the Equipment Operator (****** ****) had
exited the cab of the grader with some tools: flashlight, crowbar, crescent wrench. He
opened the back panels on the grader and had placed his tools near the rear of the grader.
6.9
A member of the public (****** ******) who was travelling on Secondary Highway
682, drove past Range Road 54 at approximately 8:30 a.m. and saw the grader parked on
the side of Range Road 54 with the back service doors open. At that time he did not see
the Equipment Operator (****** ****).
6.10
At 8:41 a.m. the Equipment Operator (****** ****) was outside of the grader, while the
grader was in 3rd gear and with the engine running. The grader moved forward, then ran
over the Equipment Operator (****** ****) and fatally injured him. The grader
continued moving forward approximately 19 m and went into the ditch on the east side of
Range Road 54. The grader blade dug into the ditch and the grader stopped moving but
the engine remained idling.
6.11
At approximately 8:44 a.m. another member of the public (**** ******) observed the
grader in the ditch and the Equipment Operator (****** ****) lying on the road. He was
the first on the scene and checked for the Equipment Operator’s ((****** ****’*) pulse.
Using his personal cell phone he called 911 and reported that a grader was in the ditch
and the Equipment Operator (****** ****) appeared to be deceased.
6.12
The RCMP and Fire Department responded to the scene. The Fairview Volunteer Fire
Department Fire Chief (***** *******) instructed the Deputy Chief to shut the grader
engine down. At 9:09 a.m., the Deputy Fire Chief (****** *******) shut down the
grader’s engine.
6.13
The Equipment Operator (****** ****) was pronounced dead at the scene. At 10:30
a.m. the RCMP notified Occupational Health and Safety of the fatality.
SECTION 7.0
ANALYSIS
7.1
Direct Cause
7.1.1
At some point while the Equipment Operator (****** ****) was outside of the cab, the
grader moved forward and ran over the Equipment Operator (****** ****) fatally
injuring him.
7
Human Services
SECTION 8.0
FOLLOW-UP/ ACTION TAKEN
8.1 Industry
8.1.1
LaPrairie Works Inc. conducted an investigation into the circumstances of the incident.
Once the grader was released back to them from Occupational Health and Safety
Investigators, LaPrairie Works Inc. had a safety mechanical inspection conducted on the
grader by the local manufacturer’s dealership, Brandt Tractor.
8.1.2
The Brant Tractor mechanical inspection report was provided to Occupational Health and
Safety. There were no mechanical deficiencies found that may have contributed to the
incident. As a precautionary measure, it was recommend the 8 shift solenoids, the shift
lever module and switch be replaced on the grader.
8.1.3
LaPrairie Works Inc. prepared a companywide safety alert reminding equipment
operators to ensure the park brake is engaged and all attachments are lowered to the
ground prior to exiting the equipment cab. Larger warning stickers displaying the
shutdown procedures were made and placed inside the equipment cabs to remind
equipment operators of the requirement (Attachment C, Photograph #7).
SECTION 9.0
SIGNATURES
Adele Tait, Lead Investigator
Date
Susanne Kachur, Manager
Date
Chris Powell, Director
Date
SECTION 10.0
ATTACHMENTS
Attachment “A”
Attachment “B”
Attachment “C”
Map
Diagram or Sketch
Photographs
8
Human Services
ATTACHMENT A
File: F- OHS-010481-68AE2
Attachment A
Page 1 of 3
Map 1
Shows the regional maintenance areas of the province with the respective road maintenance contracts
issued by the Ministry of Transportation. The red area represents the north western area maintained
by LaPrairie Works Inc.
Attachment A
Page 2 of 3
2
1
Map provided by the Ministry of Transportation 2008
Map 2
1
Shows Secondary Highway 682. The white portion of the route indicates the road is
gravel. This was the portion of the road the Equipment Operator (****** ****) was
grading on the date of the incident.
2
Shows where the LaPrairie Works Inc. satellite service yard is located in the community of
Hines Creek. It is approximately 35 km from Secondary Highway 682.
The red star shows the approximate area where the incident took place.
File:F-OHS-010481-68AE2
Attachment A
Page 3 of 3
Map 3
Shows the Hines Creek area where the LaPraire Work’s Inc. service yard is located in relation to
Secondary Highway 682. The red portion of Secondary Highway 682 indicates where the road is
gravel. The yellow star shows where the incident occurred on Range Road 54.
ATTACHMENT B
Attachment “B”
Page 1 of 1
N
R
a
n
g
e
Grader
R
o
a
d
5
4
19.8 m
4
3
2
1
4.3 m
Secondary Highway 682
Diagram 1 – Not to scale
1
Shows the position of a crowbar located 6.4 m north of the intersection of Secondary Highway 682
and Range Road 54.
2
Shows the position of a crescent wrench 7.0 m from the intersection.
3
Shows the position of a flashlight 7.9 m from the intersection.
4
Shows the location of two blade marks positioned 10.5 m and 11.2 m north of the intersection.
The yellow stars shows where the Equipment Operator (****** ****) was found 14.3 m north of
the intersection and the back left hand corner of the grader was 19.8 m north of the intersection.
ATTACHMENT C
Attachment “C”
Page 1 of 7
Photograph #1
Shows the LaPrairie Works Inc. John Deere grader Unit G2350 used by the
Equipment Operator (****** ****).
Human Services, Occupational Health and Safety
Attachment “C”
Page 2 of 7
Photograph #2
Shows the Laprairie Works Inc.’s grader Unit G2350 in the ditch along the
east side of Range Road 54 approximately 19.8 m north of the Secondary
Highway 682 intersection. The arrows are showing the open service doors
on the back end of the grader and the open cab door.
Attachment “C”
Page 3 of 7
Photograph #3
The red arrows from left to right show the tools found on the ground at the
scene of the incident: crescent wrench, flashlight, and crowbar. The
yellow star shows the approximate area where the Equipment Operator
(****** ****) was found.
Attachment “C”
Page 4 of 7
Photograph #4
This photo taken by the RCMP shows the as found position of the gear
selector in 3rd gear.
Attachment “C”
Page 5 of 7
Photograph #5
Shows the manufacturer’s warning stickers located under the steering
wheel inside the cab of the LaPrairie Works Inc.’s grader Unit 2350. The
close-up of the sticker shows the required steps to be taken prior to leaving
the operator’s seat.
Attachment “C”
Page 6 of 7
Photograph #6
Shows Secondary Highway 682 facing east. To the left of the photo as
shown by the arrow, is where the grader operator had graded the north side
of the road travelling west.
Attachment “C”
Page 7 of 7
Photograph #7
Shows the equipment shutdown procedure LaPrairie Works Inc. had made
into a sticker and placed in all heavy equipment cabs to further remind
operators of the safe operating requirements.

Equipment Operator Ran Over by Grader

Transcription

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