2007 fatality report - worker caught between tail pulley ... · 2007-05-10 · the self cleaning...

Worker Caught Between Tail Pulley and Conveyor Frame Date of Incident: May 10, 2007 Type of Incident: Fatal

April 30, 2008 Alberta Employment and Immigration, Workplace Health and Safety & Employment Standards Compliance

TABLE OF CONTENTS PAGE NUMBER SECTION 1.0 DATE AND TIME OF INCIDENT 3 SECTION 2.0 NAME & ADDRESS OF PRINCIPAL 3

STAKEHOLDER(S) - Owner(s) - Prime Contractor - Employer(s)

SECTION 3.0 DESCRIPTION OF PRINCIPAL 3

STAKEHOLDER(S) SECTION 4.0 LOCATION OF INCIDENT 3 SECTION 5.0 EQUIPMENT AND MATERIAL INVOLVED 4 SECTION 6.0 NARRATIVE DESCRIPTION OF INCIDENT 4 SECTION 7.0 ANALYSIS 5 SECTION 8.0 APPLICABLE LEGISLATION 6 SECTION 9.0 FOLLOW-UP/ACTION TAKEN 8 SECTION 10.0 SIGNATURES 9 SECTION 11.0 ATTACHMENTS 9

File: F-388761 Section 1.0 DATE AND TIME OF INCIDENT 1.1 May 10, 2007 at approximately 7:45 a.m. Section 2.0 NAME & ADDRESS OF PRINCIPAL STAKEHOLDER(S) 2.1 Owner 2.1.1 Associated Aggregates Inc. Box 90 Falun, Alberta 2.2 Employer 2.2.1 Associated Aggregates Inc. Box 90 Falun, Alberta 2.3 Contractor 2.3.1 Ledcor Alberta Limited

27420 Twp. Road 374 Red Deer, Alberta

Section 3.0 DESCRIPTION OF PRINCIPAL STAKEHOLDER(S) 3.1 Owner/Employer 3.1.1 Associated Aggregates Inc. crushes rock into various sizes of gravel according to

customer needs using rock crushing machinery. 3.2 Contractor 3.2.1 Ledcor Alberta Limited maintains and constructs roadways. 3.2.2 Ledcor Alberta Limited contracted Associated Aggregates Inc. to provide them with

gravel for construction and maintenance of roadways. Section 4.0 LOCATION OF INCIDENT 4.1 The incident occurred in a gravel pit located at LSD 31-58-16-W4, approximately 10

km southeast of Smoky Lake.


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File: F-388761 Section 5.0 EQUIPMENT AND MATERIAL INVOLVED 5.1 Cone Crusher 5.1.1 The Cone Crusher involved in this incident was manufactured by The Elrus Group of

companies, the Model number is H4800CC and serial number is M4027ERO6CC. 5.2 Self Cleaning Tail Pulley 5.1.1 The self cleaning tail pulley where the Worker became caught, was approximately

300 mm in diameter with a length of approximately 1m. It contained 9 splines and travelled at a speed of approximately 67 rpm.

Section 6.0 NARRATIVE DESCRIPTION OF INCIDENT 6.1 On May 10, 2007 at approximately 7:00 a.m., a group of 4 workers arrived at a

gravel crushing work site to operate the plant. One of the workers, who performed general labour duties, was a Groundsman, a Loader Operator operated a front end loader to fill the gravel crusher with rock, a Mechanic was servicing heavy equipment and the Tower Operator operated the plant from a central location known as a tower (Attachment “A” Photograph # 1).

6.2 At approximately 7:15 a.m. the Groundsman was directed by the Tower Operator to

go and adjust the horizontal position of the belts for the various conveyors. The Groundsman then went to adjust the position of the belts on the conveyors and eventually came to the conveyor at the base of the Cone crusher (Attachment “A” Photographs 1 & 4).

6.3 The Groundsman entered the area near the self cleaning tail pulley by crawling

under the guard door (Attachment “A” Photographs 2 & 3). The Groundsman became caught between the self cleaning tail pulley and the frame of the Cone Crusher. The conveyor belt operating on the self cleaning tail pulley stopped as a result of the Groundsman becoming caught. This automatically alerted the Tower Operator that there was a problem. The Tower Operator immediately activated the emergency stop button for the remainder of the Cone Crusher and went to investigate the reason for the conveyor belt stoppage.

6.4 When the Tower Operator arrived at and opened the access door on the east side of

the conveyor, the Tower Operator observed the Groundsman caught between the self cleaning tail pulley and the frame of the Cone Crusher. The Tower Operator alerted the Loader Operator and the Mechanic who responded to the location. The three workers determined that the Groundsman was fatally injured and local authorities were then contacted.


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File: F-388761 Section 7.0 ANALYSIS 7.1 The direct cause of the Groundsman’s fatal injuries resulted from him becoming

caught between the self cleaning tail pulley and the frame of the Cone Crusher, (Attachment “A”, Photographs 4 & 5).

7.2 The conveyor had an access door in place on both sides of the Cone crusher which

also served as a safeguard to prevent accidental contact with the self cleaning tail pulley. The Groundsman was able to crawl underneath the access door due to a large portion of the ground underneath the access door being intentionally removed for cleaning purposes, (Attachment “A”, Photographs 2 - 4).

7.3 Information obtained from the work site concluded that workers routinely adjusted

the horizontal position of conveyor belts while they were running. This was accomplished by turning a combination of adjusting bolts that allowed the conveyor belt to adjust its horizontal position on the pulleys and tail pulleys it operated on. Associated Aggregates Inc. did not recognize this as a hazard and permitted the horizontal position of the conveyor belts to be adjusted while conveyors were running.

7.4 The means to shut down the conveyor belts and lock/tag out their start/stop

mechanism was present at the work site, but was not being used by Associated Aggregates Inc. at the time of the incident. The manufacturer’s specifications for the Cone Crusher required the machinery to be shut down for any type of work to be done on the conveyors or conveyor accessories.

7.5 In order to facilitate the removal of excess gravel that would accumulate underneath

the self cleaning tail pulley for the Cone Crusher, workers used a small skid steer front end loader. In removing the excess gravel, the workers intentionally created an excavation underneath the self cleaning tail pulley and the access guard door, with the skid steer loader (Attachment “A”, Photographs 2 & 3).

7.6 The excavation, which reached a depth of approximately 810 mm from the bottom

edge of the centre of the access door to the ground, extended approximately 2.4 m in length parallel to the Cone Crusher, (Attachment “A”, Photographs 2 - 4). Using the skid steer loader in this manner allowed workers to remove the excess gravel without having to shut down the Cone Crusher and open the guard door.

7.7 The Tower Operator, who initially found the injured Groundsman, and the Loader

Operator who responded and determined that the Groundsman was deceased, stated to Workplace Health and Safety Compliance Investigators that the door on each side of the Cone Crusher was closed at the time of the incident.

7.8 The Groundsman was approximately 160 cm tall. His height would have allowed

him to easily access the underside of the guard door on the west side of the Cone crusher via the excavation in order to assess the position of the conveyor belt.


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File: F-388761 7.9 The Foreman for Associated Aggregates Inc. was not on location at the time of the

incident. He received a phone call from the owner of Associated Aggregates Inc., who was also not on location, but was contacted via telephone by workers at the site and informed of the incident. The owner advised the Foreman, via cellular telephone, to return to the work site as there was a serious accident at the location.

8.0 None of the remaining workers was in charge of the site during the Foreman’s

absence. The Groundsman was beginning his fourth day on the job, he had a total of approximately 9 months previous experience spread over two years at another gravel crushing operation near Swan Hills.

8.1 Ledcor Alberta Limited, who defined themselves as the contractor at the worksite at

the time of the incident, directed some of the activities of Associated Aggregates Inc. Ledcor Alberta Limited did not follow directives in their health, safety & environment program that outlines health and safety responsibilities of employers that are engaged by Ledcor Alberta Limited. Associated Aggregates Inc. was not made aware of Ledcor Alberta Limited’s health, safety & environment program. According to the program, Associated Aggregates Inc. was to have been “made aware of, and participate in the program and strictly abide by the requirements of the program”.

8.2 According to Ledcor Alberta Limited’s health, safety and environment program,

Associated Aggregates Inc. was to have assigned a person with knowledge and experience in safety issues who was capable of contributing to Ledcor Alberta Limited’s health, safety and environment program. This same person was to also serve on Ledcor Alberta Limited’s safety committee. Associated Aggregates Inc. personnel were not aware of the existence of Ledcor Alberta Limited’s health, safety and environment program.

8.3 No safety responsibilities were assigned to any of the Associated Aggregate Inc.

workers at the work site. At the time of the incident, no competent worker was left in charge of the work site when the Foreman left the location to attend a meeting.

Section 8.0 APPLICABLE LEGISLATION

8.1 Occupational Health and Safety Act, Section 2(1)(a)(i) Obligations of employers, workers, etc.

8.1.2 Associated Aggregates Inc. did not do what was reasonable and practicable to ensure

worker safety by controlling hazardous energy while permitting their workers to adjust operating conveyor belts. In addition, no competent person to ensure the worker’s health and safety was on site at the time of the incident and the Groundsman had not received any training in managing the control of hazardous energy.


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File: F-388761 8.2 Occupational Health and Safety Act, Section 2(1)(a)(ii) Obligations of

employers, workers, etc. 8.2.1 Ledcor Alberta Limited did not do what was reasonable and practicable to ensure the

health and safety of Associated Aggregates Inc’s. workers as they did not implement a process to ensure that Associated Aggregates Inc. complied with the Occupational Health and Safety Act, Code and Regulation.

8.3 Occupational Health and Safety Act, Section 2(5) Obligations of employers,

workers, etc. 8.3.1 Ledcor Alberta Limited took no action to ensure that Associated Aggregates Inc. had

a way to comply with the Occupational Health and Safety Act, Regulation and Code. Ledcor Alberta Limited was on location at the time of the incident directing the activities of Associated Aggregates Inc.

8.4 Occupational Health and Safety Act, Section 4(2) Multiple obligations 8.4.1 Ledcor Alberta Limited had the function of both an employer and a contractor at the

work site. Ledcor Alberta Limited did not meet the obligations of their contractor function as they took no action to ensure that Associated Aggregates Inc. complied with the Occupational Health and Safety Act, Code and Regulation. Ledcor Alberta Limited directed the activities of Associated Aggregates Inc. for the work site.

8.5 Occupational Health and Safety Regulation, Section 12(1)(b) Equipment 8.5.1 Associated Aggregates Inc. removed the dirt on the ground from underneath the

guard door on the west side of the Cone Crusher. This allowed the Groundsman to enter the unobstructed area near the self cleaning tail pulley where he became fatally injured. The guard door was intended and designed to have no access underneath it to prevent workers from entering the area in this manner.

8.6 Occupational Health and Safety Regulation, Section 15(1) and 15(2)(d)(f)(h)

Safety training 8.6.1 Associated Aggregates Inc. did not train the Groundsman in the safe operation of the

gravel crushing machinery he was required to maintain and operate. The Groundsman was told to adjust the tracking for conveyor belts as part of his duties and was permitted to do this without shutting down and isolating the hazardous energy associated with the operating conveyor belts.

8.7 Occupational Health and Safety Code, Section 7(1) Hazard assessment 8.7.1 Associated Aggregates Inc. did not assess the work site for hazards before the

incident and took no measures to control the hazard of access to the west underside of the Cone Crusher where the Groundsman became fatally injured.


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File: F-388761 8.8 Occupational Health and Safety Code, Section 12(d) Following specifications 8.8.1 Associated Aggregates Inc. did not follow the manufacturer’s specifications for the

Cone Crusher by allowing an excavation to be dug under the west underside of the Cone Crusher which permitted the Groundsman to access the conveyor of the Cone Crusher where he became fatally injured. Associated Aggregates Inc. also permitted workers to adjust the position of conveyor belts while they were running.

8.9 Occupational Health and Safety Code, Section 212(1)(a)(b) Isolation 8.9.1 Associated Aggregates Inc. allowed workers to adjust tracking on conveyor belts

without having the belts stopped or the hazardous energy from them isolated or rendered inoperative.

8.10 Occupational Health and Safety Code, Section 214(1) 8.10.1 Associated Aggregates Inc. did not ensure that the Groundsman secured the isolation

device for the Cone Crusher with a personal lock prior to the Groundsman entering the area underneath the Cone Crusher.

Section 9.0 FOLLOW-UP / ACTION TAKEN 9.1 Alberta Employment, Immigration & Industry 9.1.1 Workplace Health and Safety Compliance issued a stop work order to Associated

Aggregates Inc. for managing the control of hazardous energy. Orders were also issued to Associated Aggregates Inc. to comply with manufacturer’s specifications. This was in relation to allowing the integrity of the guard door on the west side of the Cone Crusher to be compromised by digging an excavation under the guard door which allowed worker access under the guard door.

9.1.2 Orders were written to Ledcor Alberta Limited to provide information with respect to

their role on site at the time of the incident and a copy of the evidence collected by their on-site representative.

9.2 Industry 9.2.1.1 Associated Aggregates Inc. complied with all the orders issued to them as a result of

the incident. 9.2.2 The orders written to Ledcor Alberta Limited were complied with.


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File: F-388761


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9.3 Additional Measures 9.3.1 No additional measures required at this time. Section 10.0 SIGNATURES Original Report Signed ___ ____________________ Investigator Date Original Report Signed ___ _____________________ Investigator Date Original Report Signed ___ _____________________ Team Reviewer Date Original Report Signed ___ _____________________ Senior Manager, North Date Section 11.0 ATTACHMENTS

Attachment “A” Photographs

File: F-388761 Attachment A

Page 1 of 7

Photograph #1 Photograph shows the Cone Crusher involved in the fatal injury to the Groundsman. The arrow in the center of the photograph identifies the location where the Groundsman was fatally injured. The arrow at the top shows the tower where the operation of the gravel crusher is controlled from.


File: F-388761

Attachment A Page 2 of 7

Photograph #2 The arrow on the left identifies the excavated location under the west guard door of the Cone Crusher where the Groundsman entered to begin adjusting the conveyor belt. The arrow on the right shows the difference in height, approximately 800 mm, between grade and the base of the excavated location. The guard door has been closed for photograph purposes.


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File: F-388761


Photograph #3 Photograph identifies the closed west guard door and the excavation underneath it where the Groundsman entered to adjust the conveyor belt for the Cone Crusher. The latches to open the guard door are shown by the arrows on the left and the other arrows identify the hinges for the guard door.


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File: F-388761


Photograph #4 Photograph identifies the conveyor of the Cone Crusher involved in the fatal injury to the Groundsman. The Groundsman’s clothing is wrapped around and hanging from the self cleaning tail pulley at the location of the incident.


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File: F-388761


Photograph #5 Photograph identifies a closer view of the previous photograph. In addition to the Groundsman’s clothing, his hard hat is also visible in the photograph, where it became lodged, as a result of the incident.


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File: F-388761


Photograph #6 Photograph identifies some of the cautionary signage located on the cone crusher.


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File: F-388761


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Photograph #7 Photograph identifies cautionary signage on the Cone Crusher that reflects the hazard associated with failing to lock/tag out energy sources before performing any work on the conveyor or its accessories.

2007 fatality report - worker caught between tail pulley ... · 2007-05-10 · the self cleaning...

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