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PRESENTED BY:Keven L. YarbroughAssistant Area Director Tampa Area Office 813-626-1177
Occupational Safety and Health AdministrationUS Department of Labor
OSHA AccidentInvestigations Tampa Area Office
A History of Making a DifferenceA History of Making a Difference
Since 1971:Since 1971:•• Workplace fatalities have decreased Workplace fatalities have decreased
60%60%
•• Occupational injuries and illnesses Occupational injuries and illnesses have declined 40%have declined 40%
Strong, Fair and Effective Strong, Fair and Effective EnforcementEnforcement
•• National Emphasis ProgramsNational Emphasis Programs•• Regional Emphasis ProgramsRegional Emphasis Programs•• Local Emphasis ProgramsLocal Emphasis Programs•• Site Specific Targeting Site Specific Targeting •• Enhanced Enforcement Enhanced Enforcement
Program Program •• Referral for Criminal Referral for Criminal
Prosecution, where appropriateProsecution, where appropriate•• 11(b) Enforcement11(b) Enforcement
FY 2003 – FY 2007Inspections Conducted
39,817 39,167 38,714 38,579 39,324
0
10,000
20,000
30,000
40,000
50,000
FY03 FY04 FY05 FY06 FY07
FY 2003 – FY 2007% Programmed vs. % Unprogrammed
56%
44%
55%
45%
55%
45%
56%
44%
59%
41%
0%
20%
40%
60%
80%
100%
FY03 FY04 FY05 FY06 FY07
Programmed Unprogrammed
OSHA’s Mission• To Assure So Far
as Possible Every Working Man and Woman in the Nation Safe and Healthful Working Conditions...
Company Information• Excavating/Contracting
• Site Development
• Highway & Road Construction
• Environmental Construction
• Underground Utility Construction
• Underground Pipe (water & sewer)
• Vacuuming Sewers
• Sewer - Manhole work
Company Information• SIC Code:1623, Water, Sewer, Pipeline,
Communications and Power Line Construction
• In business for 20 years, in the state of Florida for 10 years
• 6 employees at this job site; 250 nationwide, 50 in Florida and another 200 in Michigan.
• OSHA History: Several Inspections with Violations in Michigan Area.
Work to be conducted Per the County’s Contract
• Install a new updated and permanent Lift Station to handle current and future development in the general area.
• Modify an existing Temporary Lift Station (on line but not being used yet) to be utilized in line with the new Lift Station.
• Any work conducted in a “Confined Space” would require the use of a Permit (copy of permit was in the actual bid package).
Work Site Information• Work to be conducted that day:
• Completion of sealing around the by-pass pipe (was allowing ground water in).
• Clean and prepare the new Lift Station for the “sealant coating”treatment.
• Clean up - Level off the disturbed soil from the excavation process to install the new lift station (underground tank).
Work Site Operation• The Foreman was operating the loader leveling
off the site.• Employees 1 & 2 were working on/in the newly
constructed Lift Station in preparation of the sealant being applied.
• Employees 3 & 4 were working on the “Temporary Lift Station” ensuring the pipe that connects the two Lift Stations was no longer leaking (allowing water to get in).
Incident Information
• Employee 3 was a “lead” employee with several years of experience. He had gone through CS training with his old Company several years ago. He spoke fair English (oldest brother).
• Employee 4 was still new to the construction industry and in fact ended up being only 17 years of age and spoke no English (youngest brother).
Incident Information
• Employee 3 identified water had “leaked” into the TLS
• Employee 3 attempted to locate a pump strong enough to push 25+ feet vertical but had nothing on site.
• Employee 4 began to bail water out of TLS with rope & bucket
Incident Information• Employee 4 dropped the bucket filled with water
and it struck the high pressure plastic feed line behind the check-valve.
• Raw Sewage began to backfill the TLS.• Employee 1 realizing what was occurring, ran to
the street with a wrench and shut the valve off.• The TLS was approximately 15 feet deep with
waste and by-product.
Incident Information• Employee 3 told Employee 4 that since he broke
it, he had to fix it.
• Employee 4 climbed down the ladder with tools and began the repair.
• The Foreman, Employees 1,2 & 3 watched from above.
Incident / AccidentEmployee 4 complained of feeling light headed within 15-20 secondsEmployee then fell into the waste water.Employee 3 jumped in after him.Employee 1 entered with a rope.Employee 4 was secured and lifted out.Employee 1 struggled to get out.
Incident / Accident• Employee 3 was no where to be seen (he was
under the waste water).
• Foreman called 911 and advised Dispatcher of a “drowning”
• The plug was removed from the new Lift Station to allow gravity to empty most of the TLS
Emergency Response• The first of three organizations arrived to a
“drowning” only to find a CS rescue/recovery.
• The Fire Company called for assistance from the Fire Rescue (CS rescue equipped).
• No one from the Emergency Services would enter the CS (policy).
• Up to 36 ppm of H2S above manhole.
TLV = 10 ppm IDLH = 100 ppm
Attempted Rescue• Frustrated, the Foreman had Employee 2 enter
the CS and retrieve his older brother.
• EMS assisted in pulling Employee 2 & 3 out of the TLS and began an attempt to revive Employee 3.
• Employees were transported to the Hospital and treated.
RESULTS FROM ACCIDENT• Employee 1 - Overcome with noxious vapors• Employee 2 - Overcome with noxious vapors • Employee 4 - Overcome with noxious vapors. • Employee 3 – Deceased – Drowning, H2S related.
OSHA’s Enforcement• 5 Serious Violations for:
• 1926.20(b)(2) – General Safety Training• 1926.95(a) - Personal Protective Equipment• 1926.103(a) – Respiratory Protection• 1926.501(b)(4)(i) – Fall Protection• 1926.1053 - (b)(16) – Ladder - structural defect
• 2 Willful Violations for:
• 1926.21(b)(6) - Confined Space Training• 5(a)(1) - Confined Space Entry Program Safety
Procedures (ANSI Z117.1)
Stretching the Limits
Background• General Contractor hired framer• Framer hired crane to set structural
members• Employee of framer struck by crane load
and died• Inspection initiated as the result of the
fatality
Crane company information
• In business since 1985• Rents cranes, with operators – SIC 7353• 4 employees – One at site• Lifts loads of one ton or less• Primary work – set trusses at single
family residences• No prior OSHA inspections
Jobsite – Single Family Residence
The loadMicrolam beam
Consisting of two 2” x 16” x 36 foot long microlam beams with a 1/2”steel plate between the beams
Total weight, 1,850 lbs.
Bucyrus Erie H-5 Hydraulic Crane
Load was to be placed here
Load ended up here
Accident Information
• Crane boom was fully extended to 50 feet and the 26 foot homemade jib was erected
• Load was to be placed at 72 feet from the center of rotation of the crane
Accident Information• Beam was being lowered into position• Crane’s hydraulic cylinder in the main boom
failed• Telescopic cylinder collapsed and the load
shifted downward, striking one of the employees on the head and neck, inflicting injuries which resulted in his death.
Basic Cause• Unauthorized structural changes were made• Manufacturer’s limits
exceeded• Load chart limit
1,000 lbs• Attempted lift of
1,850 lbs
Manufacturer’s counterweight
Homemade counterweight
A counterweight made of steel plate and filled with concrete was added for “Cosmetic purposes, the
crane doesn’t even know it’s there”
Quote
Homemade jib designed by employer– 26 feet long
and “overbuilt”
The manufacturer did not make a jib this length
Crane Deficiencies• Crane
• No load chart• No annual inspection• No inspection prior to use• No preventive maintenance program
Leakage from main boom
hoist cylinder
Bolts attaching the main boom lift cylinder were
loose
Underside of boom damaged –deflected up ½ inch
No dead end exposed, with wire rope clip installed
to prevent accidental release
of rope from wedge socket
Main hoist rope – many broken strands and broken wires
Not taken out of service when damaged
Main hoist rope –kinking
and broken wires
No guard on No guard on main hoist drum main hoist drum
in cabin cab
Operator’s seat
Main operator control levers not marked and are Main operator control levers not marked and are out of adjustment out of adjustment –– actuation occurred near the actuation occurred near the
end of the lever travelend of the lever travel
Cuts and abrasion to sling. Red strand
showing
Not marked for Not marked for rated capacity, rated capacity,
material, or material, or manufacturermanufacturer
Floats damaged and Floats damaged and curled upcurled up Plywood Plywood
blockingblockingcrushedcrushed
Outrigger
Crack on top of outrigger
Outriggers twisted
OSHA Enforcement Action
• Willful and Serious citations were issued
Additional Information• A year later the crane company was
inspected at a different site – truss collapse
• Had been setting trusses• Using Bucyrus Crane similar to crane used
in fatal accident• Repeated and Willful violations of similar
items cited in fatal accident
I’ll Be Done in a Flash!
Company Information• ELECTRICAL
CONTRACTOR• Residential• Commercial• Light Industrial
• SIC Code: 1731• NAICS Code: 238210
Company Information• In business for 9 years• 3 employees at the job site; 15 total in the
Company• OSHA History: No history with OSHA,
had never been inspected.• OSHA Recordkeeping: Only minor
incidents, no lost time.
Work Site StructureContractual Structure
SUB Y ELECTRICAL CONTRACTOR SUB X
GENERAL CONTRACTOR
CONSTRUCTION MANAGEMENT
MAJOR BANK
Work to be Conducted• Removal of an
existing 3 phase 480 volt circuit breaker and hardware (fingers, contacts) from a Westinghouse 1,000 amp 3 phase 480 volt Main Distribution Panel (MDP).
Work to be Conducted• Install a new 30 amp 3 phase 480 volt
circuit breaker and hardware, to feed a newly installed sub-panel.
• Foreman requested MDP be shut down, through GC, who made the request to Construction Management (CM).
Work Site History• CM did not want to shut down power and
asked GC to find an alternate power source not affecting the MDP.
• EC and GC met to find an alternative. They thought they could get to a second source based on location (did not open walls or ceilings to determine).
• GC advised EC that they (GC) were behind schedule and needed to expedite the work (had to be completed that weekend).
Day of the Incident• Work crew began work on a Friday afternoon
(Bank Closed) and as they progressed, they found many obstacles that would take a substantial amount of time to overcome.
• Foreman called Owner to discuss!• Owner called GC Project Manager to discuss!
Choices to be Made• Go back to original plan and tie into the MDP.
• Shut the power off for no more than 1 hour.• Work the panel live.• Sub-contract live work specialist.
OR
CRITICAL CHOICE• Continue with the alternative and advise
GC that it will take an extra 2-3 days.
• The GC and EC spoke via phone and a decision was made (based on time element of GC, and inexperience of both) to connect directly to the MDP live and not de-energize.
CRITICAL CHOICE
Incident Information• The Owner (Master Electrician)
and the Foreman (Journeymen Electrician) began work on the MDP, removing the old breaker and contacts (fingers)
• With just the use of a pair of Salisbury Class 1 Type 1 electrical gloves and a pair of Kunz insulated glove protectors, as the only Personal Protective Equipment being used.
Incident Information• The Foreman began to loosen one of the
“fingers” when it began to shift in the direction of a second “finger”.
Incident Information• The Owner grabbed a
pair of pliers and the left glove to secure (keep from moving) the “live finger” while the screw was being removed.
Incident Information• The Foreman dropped his screwdriver
and proceeded to get another one.
• The Owner’s pliers began to lose their grip on the “finger” and he expressed the need to hurry up to the foremen.
Incident Information
• As the Foreman was bent over looking for the screwdriver, the Owner’s grip failed causing the “finger”to buck the other two phases as well as the grounded cabinet.
Incident Information
• An Arc-Blast occurred leaving both men in a daze and trying to exit the utility room as quickly as they could.
What is an Arc Blast?• High Amperage
Current arcing through air. This is initiated by contact between two energized points (generating intense heat, light, sound and pressure!).
Effects of the Incident
• Both men were seriously burned and were transported by Helicopter and Ambulance to the Burn Center.
Effects of the Incident
• Owner had 1st 2nd and 3rd degree burns and was hospitalized for 6 weeks with several months of physical and psychological therapy.
• Journeyman also suffered 1st 2nd & 3rd degree burns but very limited.
Identified Problems• DID NOT DE-ENERGIZE THE MDP.• Went against Company Safety Procedures
and Worked the MDP live.• Did not conduct a PPE Evaluation.• Conducted work in shorts and t-shirt.• Only had 1 pair of protective gloves for
protection.
Identified Problems• Not adequately trained in the recognition
of, and protection from Arc Flashes. The Company didn’t have any protective equipment for working live parts, Arc Flash Protection.
• Allowed pressure from a large GC Company to cloud his judgement.
• Naivete - “I never thought this would happen to me.”
OSHA’s Enforcement• Electrical Contractor Received:
• 5 Serious Citations• Assessment, PPE & Training
• 2 Willful Citations • Live Parts, PPE
• General Contractor Received:• 3 Serious Citations
• Live Parts, PPE & Training
Publications
Publications
www.osha.gov
•The End
• Small Employer• Non-union Shop• SIC: 1751
/Carpentry Work
• Two employees were installing 4 x 8 sheathing on the roof of a three story apartment building. Employees had installed three rows of sheathing and were not using personal protective equipment and no slide guards had been installed after the bottom row of roof sheathing had been installed.
• One employee grabbed for a piece of sheathing that had started to slide off the roof and he slipped and fell 27 feet 8 inches to the ground below, landing on his head. He died four days later.
• Two Citations Issued
• $4900
TAMPA AREA OFFICETAMPA AREA OFFICE
••OSHA ACCIDENT OSHA ACCIDENT INVESTIGAITONSINVESTIGAITONS
