12-S-19: Fatality from Failure to Observe Safe Work Zone


November 2012 www.forestresources.org/members/serpub/12-S-14.html


BACKGROUND: On a sunny summer morning in the Northeast, a feller-buncher operator and a fellow employee prepared to complete a minor repair on the feller-buncher. The fellow employee was also an equipment operator but was the designated welder for the small mechanical logging company. To complete a repair on the boom, the service truck was parked in the middle of the remote logging road. The feller-buncher had been positioned perpendicular to the service truck with the tracks on one side of the truck and the felling head grounded on the other side. This position centered the area of the boom to be welded at the back of the service truck. The service truck was an old moving van which had an aluminum ramp that slid out from beneath the floor. When pulled out two to three feet, this ramp created an elevated work platform to reach the boom. Once both machines were in position, approximately two feet apart, the ramp was extended about two feet.


PERSONAL CHARACTERISTICS: Both men had long histories as mechanical logging operators and were considered competent to complete repairs on their equipment. Neither man had completed the state’s logger training program. Both men wore hard hats and safety boots but did not wear high-visibility clothing.


UNSAFE ACT OR CONDITION: After a brief discussion, the two men agreed that the repair would be easier if the opposite side of the boom was toward the service truck. Thus, the machine would need to be moved forward about one machine length and the boom swung 180 degrees. As the feller-buncher was moved forward, the welder stood at the rear of the service truck on the passenger side. In this location, the welder was clearly in the work zone of the machine. Given a best-case scenario, there would appear to be little hazard to the welder if he remained at this location during this short maneuver.


ACCIDENT: For some reason, as the feller-buncher was in motion, the welder stepped between the track of the machine and the service truck. Perhaps he saw the extended ramp and thought it would be damaged by the tracks as they continued forward. While the specifics of this injury may never be known, the welder was somehow pinched between the tracks and some part of the service truck or the extended ramp.



INJURY: The welder received a deep wound to the inside of his right thigh. The femoral artery was completed severed. When the feller-buncher was properly positioned, the operator exited the cab and found the welder, now on the ground on the driver’s side of the service truck. The welder said he was seriously injured and would need medical help. First aid for blood loss was immediately applied. The injured employee went unconscious within approximately one minute. The remainder of the crew was notified by radio and arrived within a few minutes. CPR was administered until advanced medical services arrived in 20 to 30 minutes. A doctor arrived with the ambulance and pronounced the welder dead on the scene.


RECOMMENDATIONS FOR CORRECTION: This incident falls into the category of “Separation-of-Operations”—maintaining safe work zones. This hazard usually involves a man on the ground in the work zone of an operating piece of equipment and not being seen. Some guidelines for maintaining “Separation- of-Operations” are outlined in FRA Loss Control Overview LCO-54. Industry guidelines would dictate that a person should be in an operating machine’s work zone only when necessary. When management determines this necessity, some controls to minimize the hazard include:


• Establishing and communicating a game plan for when the machine or any machine component is moved.
• Maintaining communication: carrying a hand-held radio. • Improving your visibility: staying where you can be seen by the operator and wearing high visibility clothing.
• Unless visible or radio contact is made, no deviation from the game plan should be made. We usually think of safe work zones around equipment in the production mode but also consider the guidelines for “Separation-of-Operations” when:
• Machines converge at the fuel trailer at the end of the day.
• More than one person performs maintenance on a machine. • During morning start-up when several machines are parked at the same location. In these situations, have all individuals been accounted for before any machine is moved?


Reviewed by: Joel Swanton Northeast Region Manager


Please follow equipment manufacturers’ recommendations for safe operation and maintenance procedures.