OR-FACE Publishes Five New Fatality Reports in 2020

OR-FACE Fatality Investigator, Barbara Hanley, MPH, and OR-FACE contractor Steve Eversmeyer have published five new Fatality Investigation Reports in 2020.  The purpose of these reports is to investigate the root cause of workplace fatalities in Oregon, and to share the results to prevent further workplace injuries under similar circumstances.  The full 2020 investigation reports are available on the OR-FACE website, and cover fatalities that occurred in the industries of Crabbing/Fishing (2 reports), Construction (2 reports), and Warehousing/Storage (1 report).  A summary of each report is below.

1. Crab fishing vessel capsizes, three crew members drown

A commercial fishing vessel left a harbor on Oregon’s coast with four crewmembers to place crab pots, despite being warned about poor weather conditions and heavy seas. That afternoon while crabbing, the vessel’s external lights failed, and the Captain decided to return to port. While crossing the bar, a wave washed over the stern, capsizing the vessel. It rolled and broke apart on the rock jetty.  The Captain was thrown from the capsized vessel and was pushed by waves onto the jetty. He found someone to take him to the Coast Guard station where he reported the incident. One crewmember was recovered later that evening, deceased. A second crewmember was found approximately three weeks later, also deceased. The third missing crewmember was not found but was presumed deceased.

RECOMMENDATIONS

To help prevent similar occurrences, employers should:

  • Confirm major vessel repairs are adequate prior to sailing, especially prior to sailing in rough seas and inclement weather.
  • Before deciding to fish and venture to sea, Captains must consider weather conditions and vessel suitability.
  • If the decision is made to cross the bar in rough seas, the Captain should request and obtain a Coast Guard escort for both departing and returning crossings.
  • Vessel Owners/Employers and/or Captains should require crewmembers to don personal flotation devices (PFDs) when on deck, especially in rough seas and/or when crossing the bar.
  • Secure all potential water infiltration points in rough seas, including doors, windows, and hatch covers.
  • Captains should routinely assess job hazards and provide regular, monthly safety training and drills, including man overboard scenarios.
  • Captains should encourage crewmembers to seek out available regional safety training.

2. Crab fishing vessel capsizes, one crew member drowns

A commercial fishing vessel left a harbor on Oregon’s coast with three crewmembers to retrieve crab pots left by another vessel and crew that had capsized and sank a week prior (see above).  They collected the crabbing gear and returned to port that afternoon in rough seas.  While crossing the bar, the vessel lost power and maneuverability.  Upon losing power and steering, the Captain ordered the crewmembers to don immersion suits and notified the U.S. Coast Guard (USCG) by radio.  The Captain donned a personal flotation device (PFD).  A series of waves washed over the vessel, rolling it on its side, and throwing the crewmembers overboard.  The USCG arrived approximately 20 minutes after the radio call. The Captain and one crewmember were recovered together; the second crewmember was found 10 minutes later, face down in the water and unresponsive.  Resuscitation was attempted during transport and continued at the hospital until he was declared deceased.

RECOMMENDATIONS

To help prevent similar occurrences, employers should:

  • Confirm major vessel damage is thoroughly inspected and repaired prior to sailing, especially prior to sailing in rough seas and inclement weather.
  • Establish and follow maintenance and inspection intervals for critical components.
  • Before deciding to fish and venture to sea, Captains must consider weather conditions and vessel suitability.
  • If the decision is made to cross the bar in rough seas the Captain should request and obtain a USCG escort.
  • Secure all potential water infiltration points in rough seas, including doors, windows, and hatch covers.
  • Captains should work together to request regional safety training and encourage crewmembers to participate in available safety training.

3. Pipefitter Struck by Pressurized Pipe and Killed

On March 6, 2018, a 49-year-old pipefitter was hit in the chest by a pressurized 12-inch diameter polyvinyl chloride (PVC) pipe during a hydrostatic pressure test of a fire suppression system. The sudden pipe movement was attributed to a pipe joint connection failure in a buried section of the pipeline. The failure was due to torque shear bolts at the joint connection that were not tightened, which was missed during the utility installation process and the work inspection prior to the incident.

RECOMMENDATIONS

To help prevent similar occurrences:

  • Employers should ensure employees do not work on pressurized water systems.
  • Pipe systems should be pressure-tested and inspected before pipes are backfilled. Use checklists during tasks and the inspection process to reduce risk of overlooking critical steps that could endanger workers.
  • Prime contractors should establish a realistic project schedule in collaboration with subcontractors.
  • Prime contractors should develop and follow a communication plan so that subcontractors are made aware of project design modifications in a timely manner and to work out how design changes will impact project schedule, so as not to compromise workplace safety.
  • Employers should provide written procedures to employees prior to performing the work, and ensure employees receive adequate training and understand the hazards and how to execute procedures safely.

4. Newly hired lighting technician electrocuted while working night shift—Oregon

A 28-year-old lighting technician was electrocuted while replacing overhead light fixtures in a commercial building. The job foreman thought the lights were on a 208/120V single-phase panel, but they were on an energized 480/277V 3-phase panel. At 3:30am, co-workers found the lighting technician slumped over the scaffold. The foreman performed CPR and Emergency Medical Services were called. The worker could not be resuscitated and was pronounced dead at the scene.

RECOMMENDATIONS

To help prevent similar occurrences:

  • A competent person should be at job site to identify/mitigate safety hazards, and to stop work/secure scene when an injury occurs.
  • Employers should ensure employees de-energize circuits and use lockout/tagout procedures before work.
  • Employers should provide written procedures and training to ensure employees are able to safely perform potentially hazardous tasks.
  • All contractors and subcontractors should ensure compliance with license requirements in states where they conduct business. Especially, worker safety responsibilities should be explicitly clear between contractors, staffing agencies and/or host employers.
  • Employers should provide all appropriate PPE needed for the task.

5. Forklift Operator Crushed by Full Pallet of Soft Drink Cans 

A 47-year-old forklift operator was crushed by a loaded pallet of soft drink cans that weighed ~2000 pounds. The pallet was on the top layer of a pallet row. Pallet rows were oriented back-to-back. The warehouse inventory management system directed the operator to pull pallets from a row that didn’t contain any product. The operator pulled 4 pallets from the back of the adjoining row, destabilizing the top layer of pallets. While cleaning up some cases that fell off one of the pulled pallets, the top layer pallet fell onto operator (from a height of approximately 20 feet), causing massive internal injuries. The forklift operator worked swing shift full-time at the warehouse, as well as another job that started at 6am, working ~70 hours/week total.  Fatigue from sleep deprivation may have been a contributing factor.

RECOMMENDATIONS

To help prevent similar occurrences:

  • Ensure warehouse layout and pallet stacking procedures incorporate sufficient engineering controls to prevent distracted employees from inadvertently destabilizing multi-layer pallet rows.
  • Ensure pallet stacking procedures are written and accessible to employees, and include instructions on how to perform spot checks on pallet rows to assure they are safe. Ensure employees follow these procedures and provide retraining if an accident occurs.
  • Ensure employee training program includes training about the hazards of working around potentially unstable pallets, including awareness of potential pallet collapse areas while working on or below a live load.
  • Treat sleep deprivation as a workplace hazard, especially for swing and night shift employees.

Submitted by Barbara Hanley, MPH, and Nikolas Smart, M.S.
Oregon FACE Program, Oregon Institute of Occupational Health Sciences at OHSU

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