WORKER CRUSHED BETWEEN EQUIPMENT Type of Incident ... · 7/30/2008 · railway track. After the incident, the steel bumper of the compressor was found in contact with the bumper

WORKER CRUSHED BETWEEN EQUIPMENT Type of Incident: Fatality Date of Incident: July 30, 2008

File: F-370063

2 Alberta Employment and Immigration, Workplace Health and Safety & Employment Standards Compliance

TABLE OF CONTENTS

SECTION TITLE PAGE NUMBER

1.0 DATE AND TIME OF INCIDENT 3

2.0 NAME & ADDRESS OF PRINCIPAL PARTIES 3

2.1 Owner 3

2.2 Contractor 3

2.3 Employer 3

2.4 Prime Contractor 3

2.5 Supplier 3

2.6 Worker 3

2.7 Others 4

3.0 DESCRIPTION OF PRINCIPAL PARTIES 4

3.1 Owner 4

3.2 Employer 4

3.3 Worker 4

4.0 LOCATION OF INCIDENT 4

5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 4

5.1 Equipment and Material 4

5.2 Observations 5

6.0 NARRATIVE DESCRIPTION OF INCIDENT 5

7.0 ANALYSIS 6

7.1 Direct Cause 6

7.2 Contributing Factors 7

8.0 FOLLOW-UP/ ACTION TAKEN 7

8.1 Workplace Health and Safety Compliance 7

8.2 Industry 7

8.3 Additional Measures 8

9.0 SIGNATURES 9

10.0 ATTACHMENTS 9

File: F-370063


SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 July 30, 2008 at approximately 9:00 a.m. SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES

2.1 Owner 2.1.1 Saskatchewan Wheat Pool operating as Viterra Inc. 2625 Victoria Avenue Regina, Saskatchewan S4P 2Y6 2.2 Contractor 2.2.1 Ironhorse Railroad Contractors Ltd. Suite 1600, 246 Stewart Green S.W. Calgary, Alberta T3H 3C8 2.3 Employer 2.3.1 Ironhorse Railroad Contractors Ltd. Suite 1600, 246 Stewart Green S.W. Calgary, Alberta T3H 3C8 2.4 Prime Contractor 2.4.1 This section not applicable for this incident. 2.5 Supplier 2.5.1 This section not applicable for this incident. 2.6 Worker 2.6.1 Worker 1 (Names and personal details were removed before distribution of this report)

File: F-370063


2.7 Others 2.7.1 Royal Canadian Mounted Police Taber/Vauxhall Detachment Box 4060, 4521 Hackney Drive Taber, Alberta T1G 2C6 SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3.1 Viterra Inc. (Viterra) is a Canadian based grain handler with multiple prairie elevators

and retail agriculture products facilities, providing seed, crop protection products, equipment and agronomic advice. Viterra hired Ironhorse Railroad Contractors Ltd. to install new elevator railway tracks at the Viterra Grassy Lake grain terminal yard.

3.2 Ironhorse Railroad Contractors Ltd. (Ironhorse) constructs and maintains railway tracks in Alberta and Saskatchewan. Ironhorse has a crew of approximately 12 workers in Alberta and 10 in Saskatchewan.

3.3 Worker 1 had been employed with Ironhorse for approximately 2 years and for the last 10 months as a Tie Crane Operator. There was no record found that Worker 1 was trained on securing procedures for the push cart while checking the fuel level of the tie crane.

SECTION 4.0 LOCATION OF INCIDENT 4.1 The incident occurred on a newly installed loading railway track at the Viterra Grassy

Lake grain terminal yard located approximately 2 kilometers east of Grassy Lake, Alberta (Refer to Attachment A – Map).

SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS

5.1 Equipment and Material 5.1.1 Equipment involved in the incident was a Kershaw 4,990 kilogram tie crane (tie

crane), unit #3102-16, with front attached utility cart. This combination had all air brakes applied and was sitting stationary on the new railway track. A steel bumper and pintle hitch protruded from the back end (Refer to Attachment B – Photographs 1 and 2).

5.1.2 Other equipment involved was a Fairmont push cart (push cart) loaded with an

Ingersoll Rand P185 compressor, unit #OIA262 which was also located on the new

File: F-370063


railway track. After the incident, the steel bumper of the compressor was found in contact with the bumper of the tie crane (Refer to Attachment B – Photographs 1 and 2).

5.1.3 The newly installed railway track ran in an east-west direction. 5.1.4 A John Deere model 444J front end loader with forklift attachment was used to

unload and distribute materials at various locations on the work site (Refer Attachment B – Photograph 3).

5.2 Observations 5.2.1 The Environment Canada Weather Data Report for Grassy Lake indicated that the

wind speed was 39 kilometers per hour from the west at the time of the incident with reported gusts of 48 kilometers per hour.

5.2.2 The padlock on the fuel tank lid of the tie crane was unlocked. 5.2.3 A fuel tank dip stick was found under the push cart. 5.2.4 The fuel level in the tie crane tank was below the sight tube. 5.2.5 Rust marks were present on the railway track where the push cart had been situated

prior to the incident. No evidence was found to indicate that the push cart had previously been secured on the track.

5.2.6 Workers stated that there were heavy winds on the day of the incident. 5.2.7 The measurement taken by Workplace Health and Safety Compliance showed that

there was a negligible east/west slope on the railway track where the incident occurred.

SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On July 30, 2008 at approximately 8:00 a.m., Foreman and two Ironhorse workers

arrived at the work site. They unloaded parts from a semi-truck unit located east of the Viterra office, and moved them to the appropriate storage areas.

6.2 At approximately 8:30 a.m., the remaining six crew members arrived and all workers

met at the west end of the yard. Foreman provided parts to three workers who remained working at the west end of the yard.

File: F-370063


6.3 While these three workers continued working at the west end of the yard, the Foreman took the rest of the crew to the east end of the yard to sort out parts. He directed Worker 1 to check the level in the fuel tank of the tie crane (Refer to Attachment B – Photograph 4).

6.4 Worker 1 walked over to check the fuel level in the tie crane tank. The Foreman and

the other four workers filled boxes with joint bars and loaded them onto the utility cart hitched to the front of the tie crane.

6.5 As the Foreman climbed into the front end loader, he noticed Worker 1 lying on the

ground. The Foreman realized Worker 1 was injured and yelled at the other workers who were at the east end of the yard to go help him.

6.6 Workers ran over to Worker 1 from the east end of the yard along with the Foreman

and attended to Worker 1. They noticed that Worker 1 had suffered a broken right arm. Worker 1 indicated to co-workers that his abdominal area had been “squished”. Workers provided first aid while the Foreman called 911.

6.7 Emergency Medical Services (EMS) arrived at the work site at 9:24 a.m. EMS treated

and transported Worker 1 to the Taber Health Centre where he was pronounced dead. SECTION 7.0 ANALYSIS

7.1 Direct Cause 7.1.1 Worker 1 received fatal crush injuries when the push cart loaded with the Ingersoll

Rand compressor struck the tie crane.

File: F-370063


7.2 Contributing Factors 7.2.1 Worker 1 was attempting to manually check the fuel level of the tie crane tank while

standing between the tie crane fuel tank and the push cart. 7.2.2 The Environment Canada Weather Data Report for Grassy Lake indicated that the

wind speed was 39 kilometers per hour from the west at the time of the incident with reported gusts of 48 kilometers per hour.

7.2.3 At the time of the incident, the push cart was not adequately secured on the track to

prevent accidental movement. Measurements indicated that the push cart had been sitting approximately 5.25 meters west of the tie crane for several days prior to the incident.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN

8.1 Employment and Immigration; Workplace Health and Safety Compliance 8.1.1 Workplace Health and Safety Compliance (WHSC) received an incident notification

on July 30, 2008, responded to the scene and commenced an incident investigation. 8.1.2 WHSC issued the following orders to Ironhorse:

• Conduct an incident investigation, prepare a report and provide a copy of the

report to WHSC. • A Stop Work Order specific to work on railway tracks with wheeled carts and

equipment. • Complete a hazard assessment to identify existing or potential hazards at the

work site. • Develop and implement securing procedures for the push cart. • Workers must be trained in the safe operations of the tie crane and securing of

wheeled carts. • A Stop Use Tag was placed on the push cart. • Inspect and repair the tie crane in accordance with manufacturer’s

specifications. • Provide WHSC with a copy of worker training records, their health and safety

manual, toolbox meeting/hazard assessments and associated documentation for equipment involved in the incident.

8.2 Industry 8.2.1 After the incident, Ironhorse voluntarily stopped work prior to the arrival of WHSC. 8.2.2 Ironhorse investigated the incident, prepared a report, and submitted it to WHSC.

File: F-370063


8.2.3 Ironhorse conducted a hazard assessment, and provided acknowledgement/sign off sheets for their workers.

8.2.4 Ironhorse established standard securing procedures for the push carts, trained all

workers and provided copies of the procedures document and signed training acknowledgement forms to WHSC.

8.2.5 Ironhorse inspected and repaired the tie crane in accordance with manufacturer’s

specifications, and established a log book for the crane. 8.2.6. Ironhorse complied with all orders issued by WHSC. 8.2.7 Viterra Inc. provided WHSC with a copy of the contract with Ironhorse and a copy of

the blueprint plans for the railway track additions at the Grassy Lake yard.

8.3 Additional Measures 8.3.1 This section not applicable for this incident

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SECTION 9.0 SIGNATURES Original Report Signed_______ _____________________ Lead Investigator Date Original Report Signed_______ _____________________ Reviewer Date Original Report Signed_______ _____________________ Regional Senior Manager Date SECTION 10.0 ATTACHMENTS: Attachment A- Map. Attachment B – Photographs.

Alberta Employment and Immigration, Workplace Health and Safety & Employment Standards Compliance

File: F-370063 ATTACHMENT A MAP

Arrow shows the location where the incident occurred, at the Viterra Inc. Grassy Lake grain terminal yard, approximately two kilometers east of Grassy Lake, Alberta.


IRONHORSE RAILROAD CONTRACTORS LTD. File: F-370063 Attachment B

Photograph 1 of 4

Photograph 1 – Looking south, shows:

1. The utility cart attached to the front of the tie crane. 2. The tie crane. 3. The push cart with mounted Ingersoll Rand compressor.

East

2 3

West

1



Photograph 2 of 4

Photograph 2 – Looking south, shows:

1. The approximate location where the Worker 1 was found after the incident

2. The steel bumper of the tie crane. 3. The sight tube on the tie crane fuel tank. 4. The steel bumper of the compressor loaded on the push cart. 5. The pintle hitch of the tie crane.

5

2

4

1

3

WestEast


IRONHORSE RAILROAD CONTRACTORS LTD. File: F-370063

Attachment B Photograph 3 of 4

Photograph 3 – Shows the John Deere 444J front end loader with forklift attachment used

to unload and distribute materials at the work site.



Photograph 4 of 4

Photograph 4 – Arrow shows the sight tube on the tie crane fuel tank.

Documents

WORKER CRUSHED BETWEEN EQUIPMENT Type of Incident ... · 7/30/2008 · railway track. After the incident, the steel bumper of the compressor was found in contact with the bumper