2008 Review of Fatalities Investigated
Steve Hawkins TOSHA
2008 Fatality Investigations
Falls Struck By Overturn Equipment Crushed Electrocutions Explosion Drowning Thrown from Equipment Confined Space Total 15 14 3 1 1 1 1 1 1 (2) 38 (39)
Construction Fatalities
18 of 38 were from the Construction Industry Falls Struck By Electrocution Overturned Equipment 5 7 1 1
Fall from Elevation During Maintenance Work on Roof
Fall from elevation
Where victim was working
Extension cord
Where victim landed
Stuck by tree during logging
Crane striking power line
Fall from elevation
Where employee fell
Fall From Elevation
Ladder to the transformer mezzanine
Fall from ladder
Pipe support
Grinder
Truck rolled during repair
Truck which ran over the victim
Struck by log during logging
Red arrow indicates location of the victim
White arrow indicates dead maple tree
Catastrophe 3 employees fell
Crushed While Repairing Hydraulic System
Struck by Loader
Approx. position of the loader when the incident occurred
Ramp
Drown in Rushing Water
Area where the car entered the ditch
Employee fell while boarding crane
Scrap area with crane Crane boarding platform after accident
Fall through floor hole
Hole
Plywood cover as it was in place before the accident Yellow arrow-where it was secured to the concrete floor Red arrow-1-inch lip the cover was sitting on
Shaft on 2nd floor where the victim as found
Stuck by monument
Monument that fell on the victim
Trailer used to deliver the monuments
Tractor used to lift the monument
Struck by cable
Lift roll-over
Arrow indicates where the employee was pinned
Thrown from dozier
Berm
Loc. Of Victim
Employee struck by rolling vehicle
Fall from elevated work platform during demolition
Truck struck operator (no brakes)
Truck
Tracks
Struck by log
Yellow outline = where log was before it was pulled out Red arrow = stump the log got caught on Blue arrow = location of the victim Green arrow = log after it struck the victim
Two employees died in confined space
Sewer pump station where employees died
Struck by crane boom
Boom struck employee
Boom struck employee
Employees working near holes
Roller roll-over
Pieces of the reflective vest worn by the victim
Struck by falling grate
How racks were placed for blasting
Rack that struck the victim
Fall from tree during trimming
Tree from which the victim fell Breaking point of the rope
Struck By Boom Lift
PIT which struck the victim
Where the PIT struck the victim
Oil storage tank explosion
Fall from Articulating Boom Lift
Bucket from which the employee fell
Fall during re-roofing
Where he fell
Where he landed
Struck by Skid Steer Loader
Green arrow—where the engine cut off Red arrow—sod that was run over Yellow arrow—where the victim landed
Two Fork Lift Collision
PITs involved in the incident
Fall during roofing activities
Where the employee fell
Nylon rope
Fall from broken manlift
Belt manlift the victim was riding
Broken step
Fall from roof during roofing work
Roof edge where employee fell
Crushed by Automobile
Car that fell on the victim
Fall from Step Ladder
Feeder bin the victim was working inside Opening where the victim's body extended
Inside the bin
Fatality Investigation Review
Looking Beyond the Obvious
Boring a Hole
Employee boring a horizontal hole in a concrete block wall to allow a pipe to penetrate Working from a step ladder Employee was training on ladder use Employee received a fatal head injury suffered during a fall from the ladder
Causes
DeWalt Grinder rated at 6,000 rpms Bit Max RPM 2500 .095 BAC
Moving a Crane
Crane operator moving crane from one operating location to another No load on crane Weather conditions partly cloudy Crane operator trained and experienced Crane boom contacts high voltage power line Crane operator dies of electric shock at the moment he exits the crane cab3 Crane operator had followed similar path previously
Causes
Poor visibility, sun in eyes No spotter No physical barrier (barricades) No line insulation No preplanning or JSA Crane operator misjudgment of situation
Truck rolled during repair
Employee performing maintenance on bucket truck Working specifically on the power steering pump from under the truck Truck running, in neutral Suddenly, unexplainably, lunges backwards
Causes
Truck not scotched Engine left running Others in area not aware of location of other employee
Repairing Pump in Lift Station
Employees assigned to replace broken pump bracket One employee entered and was unable to exit lift station Second employee entered and was unable to exit lift station Third employee decided not to enter and left area to contact emergency services
Causes
No PRCS Entry Program No PRCS Entry Procedures established No PRCS Precautions taken Atmospheric conditions unable to be documented Electrical violations present Autopsy documents drowning as cause of death
Lessons Learned
Immediate cause is not generally root cause or the place changes may need to be made Information gathered from witnesses may or may not be of value All information must be gathered and weighted appropriately Employee misconduct/misjudgment is a seldom a root cause and may side track investigation
Lessons Learned
There is no substitute for in-depth investigation, analysis, discussion Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question, Question,