Fatality Narrative: Mechanic Crushed by Bin Destacker

Details

• Corporate Authors:
  Washington (State). Department of Labor and Industries
• Description:
  In December 2014, a 34-year-old mechanic doing maintenance on a bin destacker at a fruit packing plant died when part of the machinery came down, crushing him. He had worked for his employer, a grower and packer of tree fruits, for nearly a year. On the day of the incident, he was working alone changing a hydraulic cylinder on a fully automated bin destacker. The hydraulic cylinder raised and lowered the machine's forklift assembly. It was located on the right side of the forklift assembly where the control panel was located. He was not supposed to be changing this cylinder by himself. He had never changed this cylinder before; he had only observed another employee doing it. He turned the machine off before starting work, but there was residual energy in the hydraulic line to the forklift assembly. For an unknown reason, he raised the forks and climbed onto the rollers to access the pressure fitting on the hydraulic line to the forklift assembly. It was not necessary for him to be on the rollers under the forklift assembly. The fitting was located under the rollers and behind the cylinder he intended to replace. Both could be accessed from the outside of the destacker on its right side. He did not use any method of restraining the forks. The employer required that a chain be wrapped around the assembly to anchor it to the destacker frame for work under the forklift assembly. As he kneeled on the rollers underneath the forklift assembly, he used a wrench to release a pressure fitting that then disconnected the hydraulic line. Without the hydraulic pressure, the forklift assembly, weighing between 600 and 700 pounds, came down and crushed his neck and shoulders. The coroner reported that the victim died of 'traumatic asphyxia due to mechanical compression of torso." Investigators found that: there were no written procedures for mechanics at the plant on how to perform lockout/tagout for specific equipment; not all mechanics were provided with energy control procedures training; and the victim did not make sure that there was no stored energy on the forklift assembly when he loosened the fittings on the hydraulic hose. [Description provided by NIOSH]
• Subjects:
  Automation Environmental Exposure Hazardous Substances Occupational Health Risk Assessment Risk Factors Safety Workplace
• Keywords:
  Equipment Maintenance Equipment Operation Exposure Levels Forklifts Hazard Identification Hazards Hydraulic Equipment Injuries Lockout Tagout Risk Factors Task Performance Traumatic Injuries Work Environment Workers

  More +
• Series:
  Fatality Assessment and Control Evaluation Reports (FACE)
• Publisher:
  Washington State Department of Labor and Industries
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Report
• Place as Subject:
  OSHA Region 10 ; Washington
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  1
• NIOSHTIC Number:
  nn:20051384
• Citation:
  Olympia, WA: Washington State Department of Labor and Industries, 71-165-2017, 2017 Dec; :1
• Federal Fiscal Year:
  2018
• Performing Organization:
  Washington State Department of Labor and Industries
• Peer Reviewed:
  False
• Start Date:
  20050701
• Source Full Name:
  Fatality narrative: mechanic crushed by bin destacker
• End Date:
  20260630
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:54ffa56b7f2020b05c2e566ecbe4238ff133cc304a550e48371227b487327cd15ccfc0fa0217db50681d00750ce99cdd40835c9641cdbb9efbfc067898b3b295
• Download URL:
  https://stacks.cdc.gov/view/cdc/228717/cdc_228717_DS1.pdf
• File Type:
  [PDF - 408.70 KB ]