Investigation Report Worker Fatality Injured After Being ... · 11/23/2015 · On November 23,...
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Report No-F-OHS-097772-3A56D
December 2018
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Investigation Report
Worker Fatality Injured After Being Entangled in Rotating Equipment
November 23, 2015
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The contents of this report This document reports Occupational Health and Safety’s investigation of a fatal incident in November
2015. It begins with a short summary of what happened. The rest of the report covers this same
information in greater detail.
Incident summary A worker was installing handrails on tower #30 of the West Fraser Mill Ltd. Pulp and Paper Mill in
Hinton, Alberta (AB) when the worker became entangled in a rake drive and was fatally injured.
Background information West Fraser Mills Ltd. (West Fraser) was founded in 1955 and became the largest lumber producer in
North America. A diversified North American wood products company, West Fraser operated over 45
manufacturing facilities in Western Canada and the southern United States.
West Fraser supplied wood chip fibre necessary for pulp operations from their lumber mills. West Fraser
was a long term producer of wood pulp in western Canada.
Winfield Industrial Sales Ltd. (Winfield) was a small employer based in Hinton, AB that provided
welding and fabrication services, machinery installation and industrial maintenance.
Winfield was hired by West Fraser to install handrails on tower #30 and employed worker 1 who was
fatally injured.
Worker 1 was hired by Winfield in June of 2015 as a welder apprentice and labourer. Worker 1 had two
years previous work experience as a heavy duty mechanic. At the time of the incident, worker 1 had up to
date relevant tickets and certifications. Worker 1 had received indoctrination training at the plant prior to
the incident.
Worker 2 was hired as a sub contractor by Winfield one year prior to the incident. Worker 2 had up to
date tickets and certifications with the exception of fall protection training. Worker 2 had ten years of
relevant industry experience.
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Equipment and materials West Fraser Mill Ltd. Hinton Pulp and Paper Mill
Figure 1. Overview of the Hinton Pulp and Paper Mill owned by West Fraser Mills.
West Fraser produced Northern Bleached Softwood Kraft (NBSK) pulp. Chemical pulp combined
woodchips and chemicals into what was called a digester. The chemical process in the digester broke
down the lignin in the fibre. Lignin was the glue that held fibres together.
NBSK pulp in its finished form was made up of long slender fibres that provided bonding and tensile
properties. NBSK pulp was used for manufacturing a variety of paper products including printing and
writing paper, specialty grades and a range of tissue products.
West Fraser hired Winfield to install handrails on tower #30.
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Figure 2. Incident occurred on the roof top of tower #30. Tower #30 is a 38.7 metre (125 foot) up flow
tower. The tower emitted chlorine dioxide as shown above on the right hand side of photo.
A. Incident location.
A
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Chlorine Dioxide (ClO₂)
Material Safety Data Sheet (MSDS)
Figure 3. MSDS for reference on the consequences to chlorine dioxide exposure.
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Figure 4. Information provided by West Fraser as response to a Section 19 Demand.
The cartridge worn by the deceased worker was tested and it was confirmed that chlorine dioxide was not
a contributing factor to the incident as breakthrough did not occur through worker 1’s half mask. The
testing was conducted by an independent laboratory recommended by the manufacturer in the USA. A
report was produced explaining the results of the testing.
Rake Drive
Worker 1 became entangled on the coupling of the rake drive of the rake shaft. Worker 1 was standing on
the I-beam closest to the rake drive (Figure 5).
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Figure 5. Photo was provided by West Fraser the day of the incident and marked by worker 2 during
worker 2’s interview.
A. The rake shaft was located on the underside of the tower lid and scraped pulp off the lid
during the bleaching process.
B. The coupling turned the rake shaft and was the exposed piece of moving equipment which
pulled worker 1 in.
C. Represents the placement of worker 1’s feet while worker 1 was crouching down and
lubricating the drill bit while worker 2 was boring the holes.
D. The opening worker 1 was pulled into the rake drive.
E. Represents where worker 2 was located. Worker 2 was facing worker 1 while crouching
down. Worker 2 was completing the last two holes closest to worker 2 when worker 1 was
pulled into the rake drive presumably by worker 1’s lanyard. Worker 1’s lanyard was not tied
to an anchor point and was slung under worker 1’s arm from the back dorsal ring to the front
of worker 1’s harness.
A
B
C
D
E
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Figure 6. photo taken facing west.
A. Completed handrail on the north side of rake drive.
B. Beam worker 1 was crouching on when worker 1was pulled into the rake drive.
Rake Drive Opening
In November 2015, Winfield was hired by West Fraser to install handrails around the rake shaft rake
drive on top of tower #30. The lid of tower #30 was fibreglass and could not safely support weight as the
chemicals emitted from the tower degraded the integrity of the lid. The handrails would allow workers to
safely stand on the tower metal grating near the gear shaft without fall protection and protect them from
falling through the lid or off the tower 38.7 m to the ground.
The handrail was to be secured to the I-beams which were parallel on the north and south side of the rake
drive. The I-beams were approximately 50 cm from the moving rake drive (Figure 5).
A
B
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Figure 7. Rake drive with fall protection showing in bottom left corner.
A. Worker 1 was located directly above the rake drive and was estimated to be approximately 10
centimetres (cm) between the I-beam and the rake drive.
B. The measurement depicts the distance of 20.5 cm between the I-beam and worker 2 while
drilling the holes for the handrails.
C. Fall protection wrapped around the rake drive coupling worn by worker 1.
A
B
C
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Personal Fall Protection Harness
Figure 8. Photo taken from the manufacturer Honeywell’s website as an example of what a complete
harness looks like.
The harness worn by worker 1 was ripped and damaged during the incident as it was wrapped around the
rake drive.
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Lanyard
Figure 9. Photo taken from the manufacturer Honeywell’s website and is an example of the lanyard worn
by worker 1 at the time of incident.
The lanyard was wrapped around the rake drive at the time of the incident.
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Half Mask Respirator with cartridge
Figure 10. Model of North 7700-30M half mask respirator with Honeywell Class 1 cartridges worn by
worker 1 and worker 2 at the time of the incident. Photo taken from the manufacturer Honeywell’s
website.
As mentioned previously, the cartridges were sent to a laboratory recommended by the manufacturer for
testing at Assay Technology, 1382 Stealth St, Livermore, CA 94551 to establish that chlorine dioxide
was not a factor in the incident. The independent laboratory confirmed breakthrough of chlorine dioxide
had not occurred.
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Magnetic Drill
Figure 11. The magnetic drill used by worker 2 to drill the holes to bolt on the hand rails to the I-beam.
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Sequence of events On November 2, 2015, the Winfield supervisor (supervisor) and the West Fraser project manager (project
manager) conducted a meeting and a Pre-Job Plan for the handrail installation project. The meeting took
place in the project manager’s office where the supervisor was shown a photo of the work site area. The
supervisor then went to the tower #30 worksite unescorted to assess if the Winfield crew could complete
the job. The supervisor returned to the project manager’s office and agreed to complete the job. While
both the project manager and supervisor acknowledged the moving parts of the drive shaft and discussed
the management and control of hazardous energy, it was determined by both parties that it was not
necessary to lock-out the machinery. The rake drive coupling was moving so slowly that it was not
perceived to be a hazard despite the “narrow restrictive work area” (recorded on the T30 Initial Hazard
Assessment Meeting) and awkward footing, and it would slow down the project.
On November 17, 2015, the supervisor returned to the West Fraser Mill with worker 1 and worker 2 to set
up the supplies for the handrail installation. The crew completed a Safe Work Permit which was verified
by a plant operator. The crew attended the worksite unescorted and began conducting the handrail
installation. The handrails were not fitting properly so they stopped early.
On November 18 and 19, 2015, worker 1 and worker 2 re-attended the worksite on tower #30 and
continued to install the handrails. Both days the work was cut short for various reasons. November 18,
2015 worker 1 and worker 2 took new fabricated handrails back to the site to ensure they would fit
properly. Work stopped mid-day due to snow and cold weather.
On November 19, 2015, the work resumed at the site; however, the drill bits kept breaking as they were
drilling through stainless steel.
On November 20, 2015, workers 1 and 2 continued the handrail installation, but they had to shut down
the job due to high levels of chlorine dioxide as reflected on the Safe Work Permit. The gas they were
referring to was chlorine dioxide (for MSDS reference see Figure 3).
On November 23, 2015, prior to work commencement, worker 1, worker 2 and the supervisor practiced
using the new drill bits at the Winfield shop to ensure they were strong enough to finish the task. At that
time, the supervisor provided worker 1 with a new self-retracting lanyard to use on tower #30. The
supervisor confirmed worker 1 was familiar with the required fall protection system. The supervisor was
confident worker 1 was familiar with how to use the lanyard as they had worked together on a previous
worksite and used the same system.
At 9:15 a.m. on November 23, 2015, the workers returned to the worksite, and worker 1 signed the Safe
Work Permit. The workers resumed the handrail installation on tower #30.
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While completing the last section of handrail, worker 2 was crouching down to use a magnetic drill to
make the last two holes for the bolts to secure the handrail to the I-beam. Worker 1 was also crouching
down in front of worker 2 and lubricating the drill hole with a spray bottle. Both workers were wearing
fall arrest harnesses with a lanyard attached to their dorsal rings and slung under their arms secured to the
front of their harnesses. The lanyards created a loop which hung down to their mid-thigh area while
standing. Neither worker had their lanyard tied off to the engineered anchors that were located on the
tower roof close to the catwalk platform.
While worker 2 was boring the second to last hole required for task completion, worker 1 was suddenly
pulled into the rake drive feet-first. Worker 1 was pulled by worker 1’s lanyard which wrapped around the
rake drive coupling. Once worker 1 was pulled into the equipment, worker 1 made a full rotation before
the machine stopped. Worker 1 was entangled around the coupling and was wedged between the rake
drive and a metal bar. Worker 1’s fall arrest harness was also pulled tightly around worker 1’s neck. The
metal bar acted as a shadow effect switch and its purpose was to monitor the gear drive to ensure it was
rotating normally. The shadow effect switch was a control measure that if moved off its point of contact
would de-energize the moving equipment. The injured worker’s body forced the bar out of position,
tripped out the machine and alerted the control room operator that tower #30 was not operating as normal.
Worker 2 immediately used worker 2’s cell phone and called a co-worker at the Winfield shop for
assistance. The co-worker put the supervisor on the phone. Worker 2 then ran down from the tower #30
roof to the fifth floor calling for help from West Fraser personnel.
At 4:50 p.m., onsite West Fraser personnel initiated the plant Emergency Response Plan and the plant
Emergency Response Team was called. The Emergency Response Team and an onsite nurse arrived at
5:05 p.m., and the site nurse pronounced worker 1 deceased.
At 5:07 p.m., the Royal Canadian Mounted Police (RCMP) were called and arrived at 5:21 p.m. The
Hinton paramedics arrived on scene and confirmed worker 1 deceased. The scene was secured by RCMP
until Occupational Health and Safety’s (OHS) arrival.
The incident was reported to OHS at 5:41 p.m., on November 23, 2015, by the Hinton RCMP and again
at 5:46 p.m., by West Fraser. OHS arrived at the site at 9:07 a.m., on November 24, 2015.
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Completion A review for enforcement action was completed on January 13, 2016, and it was determined that the file would be referred to Alberta Justice for review. The entire file was sent to Alberta Justice on June 7, 2016. Charges were laid on November 16, 2017.
On December 3, 2018, Winfield Industrial Sales Ltd. pled guilty to Section 139(1)(b) of the OHS Code, failure to ensure that workers used a fall protection system at a temporary work area where a worker could fall a vertical distance of less than 3 m if there was an unusual possibility of injury. They were fined $5000 inclusive of the 15% Victim Fine Surcharge. In addition, they were ordered under the OHS Act Section 75 to pay $295 000 in favour of the Alberta Forest Products Association (AFPA) to develop and make available to industry participants, an educational program concerning fall protection, energy isolation and safeguards against harm. The 2019 AFPA annual conference will also hold a spot on the agenda to discuss the circumstances and learnings from this fatal incident.
This investigation was closed on December 4, 2018.
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Signatures
ORIGINAL REPORT SIGNED December 9, 2018
Lead Investigator Date
ORIGINAL REPORT SIGNED December 10, 2018
Manager Date
ORIGINAL REPORT SIGNED January 10, 2019
Director Date