2012 Fatality Report: Worker crushed by trailer ramp€¦ · Worker Crushed by Trailer Ramp Type of...

1 Alberta Human Services, Occupational Health and Safety

Worker Crushed by Trailer Ramp

Type of Incident: Fatality

Date of Incident: June 21, 2012

File: F – OHS-025895-DE2E5


SECTION 1.0 DATE AND TIME OF INCIDENT

1.1 June 21, 2012 Approximately at 17:00

SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES

2.1 Owner(s)

2.1.1 Town of Cochrane

101 Ranch House Road

Cochrane, Alberta T4C 2K8

2.2 Prime Contractor

2.2.1 N/A

2.3 Employer(s)

2.3.1 Town of Cochrane

101 Ranch House Road

Cochrane, Alberta T4C 2K8

2.4 Contractor(s)

2.4.1 N/A

2.5 Supplier(s)

2.5.1 N/A

2.6 Worker(s)

2.6.1 *****************

**********************

********************

2.7 Others

2.7.1 RCMP Cochrane detachment

(Names and personal details were removed before distribution of this report)



SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES

3.1.1 The Town of Cochrane was the employer of the worker (*****************).

3.1.2 The Town of Cochrane employs approximately 250 workers and an additional 30-50

summer workers.

3.1.3 The deceased worker (*****************) was a parks operator and had been

working for the city for approximately 18 months. He had 12 years of experience in

similar work.

SECTION 4.0 LOCATION OF INCIDENT

4.1.1 The incident occurred in the yard of the Town of Cochrane located at 124 Griffin

Road East, Cochrane, Alberta T4C 2K8 (Refer to Attachment A- Map and

Attachment B - Photographs 1, 2 and 3).

SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS

5.1 Equipment and Material

5.1.1 A 30 feet (9.14 metres ) long 2010 Loadmax Gooseneck trailer model LPG30 (trailer)

manufactured by Load Trail Utility Trailers and equipped with a hydraulic dovetail

ramp (ramp). It had a Gross Vehicular Weight (GVW) of 24,000 lbs and VIN

5L8GP3020A1018871.

5.1.2 The ramp is operated by a hydraulic pump powered by a battery. The control is

located on the curb side of the trailer in a lockable box. The hydraulic pump is

connected to two rams to lift the ramp up or down. Each ram is connected to the

hydraulic system by two hoses. The rams are connected in series making both rams

disabled when a hydraulic hose attached to one ram is disconnected. When the ramp

is in the raised position, there is a mechanical locking mechanism. (Refer to

Attachment B - Photographs 4, 5 and 6).

5.2 Observations

5.2.1 There was no Commercial Vehicle Inspection Program (CVIP) inspection sticker on

the trailer. There were no safety stands or blocks underneath the ramp. The safety

lock pin was hanging from its chain and was not in place. The ram on the right hand

side was disconnected from the ear on the supporting bar and the top hydraulic hose

was disconnected from the ram. The lock mechanism latch had burn marks on it and a

pin on it was bent. The spring attached to the locking mechanism had burn marks and

was stretched out and did not appear to have the normal tension. There was hydraulic

fluid on the board the injured worker was laying on. The Hydraulic fluid level in the



hydraulic pump tank was below the minimum fill line (Refer to Attachment B -

Photograph 7).

SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT

6.1 On June 6, 2012, seasonal worker 1 (**********) and seasonal worker 2 (****

********) loaded a tractor onto the trailer at a Calgary maintenance shop to transport

it back to Cochrane yard. When they operated the ramp while picking up the tractor,

they noticed that hydraulic oil was leaking from the right hand side ram of the ramp.

6.2 When they inspected the ram, they observed that the brace attached to the frame

connecting the ram to the frame had broken and hydraulic fluid was leaking from the

hose attached to the ram. They returned to the Cochrane yard with the trailer and

reported the problem to the parks and facilities manager (***************) and

Parks Operator (*****************) of what they observed.

6.3 On June 21, 2012, contract welder (*********) re-welded the brace to the frame as

instructed by Parks Operator (*****************). The ram was left unattached to

the brace.

6.4 At approximately 3:40 pm, Roads Operator (*************) was walking to the

grader parked beside the trailer when Parks Operator (*************) requested his

assistance. The Parks Operator (*****************) was lying under the ramp and

wanted to re-attach the ram to the bracket.

6.5 After the Roads Operator (*************) pointed out that the Parks Operator

(*****************) was in an unsafe place, the Parks Operator (*******

*********) positioned himself behind the right hand side wheel under the trailer.

6.6 On the request of the Parks Operator (*****************), Roads Operator (****

********) operated the hydraulic controls to raise and lower the ramp twice. Both

observed that there was a hydraulic fluid leak from the hose.

6.7 The Parks Operator (*****************) said that he would need to get the

hydraulic hose fixed. The Roads Operator (*************) raised the ramp back up

and left when the Parks Operator (*************) took a call on his cell phone.

6.8 Just before 5:00 pm, workers were by the gate waiting to leave work when they

noticed that the Parks Operator’s (*****************) vehicle was parked but he

was nowhere to be seen. Two workers (************* and ************) walked

towards the trailer after the Parks Operator (*************) failed to answer his cell

phone.



6.9 The workers (************ and ************) saw him under the trailer and

alerted the other workers and Cochrane Emergency Medical Services (EMS). The

ramp was jacked up and the injured Parks Operator (*****************) pulled out.

Emergency medical assistance was provided by co-workers until EMS arrived. The

injured Parks Operator (*****************) was non responsive and was

pronounced dead at the scene.

SECTION 7.0 ANALYSIS

7.1 Direct Cause

7.1.1 The ramp fell on the Parks Operator (*****************) who was underneath.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN

8.1 Industry

8.1.1 On June 21, 2012 following the incident, The Town of Cochrane secured the scene

prior to the arrival of OHS.

8.1.2 The Town of Cochrane returned the trailer to the dealer to be repaired and recertified.

Damaged parts of the dovetail locking mechanism were replaced and the trailer was

recertified by the dealer.

8.1.3 The employer conducted an incident investigation and submitted a copy of the report

to OHS.

8.1.4 The employer complied with all orders and demands issued by OHS.

8.2 Additional Measures

8.2.1 The Town of Cochrane removed the trailer from service.



SECTION 9.0 SIGNATURES

“ORIGINAL REPORT SIGNED” February 12, 2014

***************, Lead Investigator Date


*********, Reviewer Date


************, Director of Investigations Date

SECTION 10.0 ATTACHMENTS:

Attachment A - Map

Attachment B - Photographs

TOWN OF COCHRANE File: OHS-025895-DE2E5

Attachment A

Map

Map – The arrow shows the location of the incident in Cochrane, Alberta.


Attachment B

Photograph 1 of 7

Photograph 1 – Shows the front entrance to the facility


Attachment B

Photograph 2 of 7

Photograph 2 – Shows the back of the yard where the trailer was parked. The arrow points

to the Gooseneck trailer


Attachment B

Photograph 3 of 7

Photograph 3 – Shows the Gooseneck trailer involved in the incident


Attachment B

Photograph 4 of 7

Photograph 4 – Shows the Right hand side ram partially detached from the trailer frame.

1. Shows the detached end of the ram

2. Shows the partially detached ram

3. Shows the ram inlet where the hose had been disconnected

4. Shows the Left ram attached to the frame

1

2

3

4


Attachment B

Photograph 5 of 7

Photograph 5 – Shows the locking pin disengaged from the locking lever.


Attachment B

Photograph 6 of 7

Photograph 3 – Shows the burn marks on the locking mechanism and the attached spring.

1. Shows the burn marks on the locking arm

2. Shows the stretching on the spring

1

2


Attachment B

Photograph 7 of 7

Photograph 7 – Shows the hydraulic fluid level below the minimum fill level

2012 Fatality Report: Worker crushed by trailer ramp€¦ · Worker Crushed by Trailer Ramp Type of...

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