BOI Fatality Lessons Learned 23 Sep 2011

7/31/2019 BOI Fatality Lessons Learned 23 Sep 2011

1/11

US Army Corps of Engineers

BUILDING STRONG

Board of Investigation (BOI) ReportContractor Fatality at ANP Site

23 September 2011


2/11

BUILDING STRONG

BOI Members (Voting Members)

Edwin Cuebas (President)

Charles Comeau (Member) Edwin Perdue (Member)

BOI Advisor (Non-voting members)

Patrick Freedman Technical

Board of Investigation (BOI) ReportContractor Fatality ANP Site

2


3/11

BUILDING STRONG


Accident Information:

Date: 23 September 2011

Location:XXXXXXXXX

Prime Contractor:XXXXXXXXX

Result: Worker killed while operating a concrete mixer Background:

A concrete mixer operator was cleaning our his concrete mixer inpreparation for lunch

A worker near the mixer heard a noise and turned to find the

mixer operator lying on the ground next to the concrete mixerwith injuries to back

Injured operator was transported to the District medical clinicwhere he later expired from his injuries

3


4/11

BUILDING STRONG

Project Site Layout

4


5/11

BUILDING STRONG

In the photo below, a worker demonstrates the position in which the injuredoperator was found relative the concrete mixer and the mixers loading chute.

5


6/11

BUILDING STRONG


Direct Cause: The concrete mixers loading bin lowered rapidly striking thevictim and knocking him to the ground.

Indirect Causes:

Lack of an effective safety program to include the lack of training on the

proper operation of equipment such as the concrete mixer.

Contributing Factors:

Conducting concrete mixing operations with only one person created anenvironment more prone to accidents due to the lack of a buddy system.

The operator became complacent due to the lack follow up safetymeetings to remind the operator of the potential hazards while operatingthe equipment.

Worksite was 65 miles from the nearest medical center.

6


7/11

BUILDING STRONG


Recommendations: Set up a formal training program for personnel operating and working

around this type of concrete mixer. The program should as a minimumcover proper startup, operation, and shutdown of the concrete mixer as wellas the potential hazards associated with the equipment.

Develop a proper AHA for this activity and ensure that three phase

inspections are properly conducted for the activity.

Always have two personnel present during operation of the concrete mixer.

USACE shall ensure Contractor is implementing an acceptable AccidentPrevention Plan & is submitted for review & acceptance

USACE shall ensure the job site is in compliance with the Safety & Health

Requirements Manual (EM 385-1-1)

7


8/11

BUILDING STRONG


Recommendations (cont.): USACE shall ensure the job site is in compliance with the Safety &

Health Requirements Manual (EM 385-1-1)

USACE shall periodically attend Contractors weekly toolboxmeetings to ensure safety standards are being implemented

properly USACE shall ensure all safety requirements are being maintained

by the Contractor based on EM 385-1-1

USACE shall audit the Contractors safety training records

8


9/11

BUILDING STRONG


Accident Prevention Items: Contractor shall address all recommendations in their Accident

Prevention Plan (APP) and submitted for review and acceptanceby date here

USACE Safety Officer shall track APP progress to assure

acceptance is done by date here USACE Project Engineer shall audit the Contractors employee

training documents on date here

9


10/11

BUILDING STRONG


The Board thanks the following for their supportduring the investigation:

Feyzabad Resident Office

Mazar-e-Sharif Area Office

Office of Counsel Safety Office

10


11/11

BUILDING STRONG


Questions?

11

BOI Fatality Lessons Learned 23 Sep 2011

Documents

Transcript of BOI Fatality Lessons Learned 23 Sep 2011