Lessons from the Field - One Step Too Far | Fatal Hopper Incident Re-enacted — Transcript

Full transcript

1. 0:18On July 23rd, 2021,
2. 0:21a 66-year-old employee was working for
3. 0:24the company as an equipment operator
4. 0:26when the incident occurred.
5. 0:28On their first day, the employee
6. 0:30completed an orientation covering the
7. 0:32occupational health and safety
8. 0:34management system, including safety
9. 0:36rules, rights and responsibilities,
10. 0:38hazard management, personal protective
11. 0:41equipment, safe work procedures,
12. 0:44emergency protocols, and hazard
13. 0:46reporting.
14. 0:48Employees are expected to assess any new
15. 0:50or modified hazards they encounter.
16. 0:53The employee reviewed and signed a
17. 0:55hazard assessment specific to their role
18. 0:57as an equipment operator, addressing
19. 0:59hazards like equipment access and
20. 1:01material handling.
21. 1:03No record exists of a hazard assessment
22. 1:05on the day of the incident.
23. 1:08On the day of the incident, the employee
24. 1:10was tasked by his supervisor to empty
25. 1:12material out of bin three and bin four
26. 1:14of the plant so that new material could
27. 1:16be added.
28. 1:18The weather was quite warm that day, 28°
29. 1:20C.
30. 1:22The task of emptying material from the
31. 1:24plant's bins required the employee to
32. 1:26push the material toward the small
33. 1:28conveyor belt at the bottom of each bin.
34. 1:31To carry out this task, the employee
35. 1:33climbed a ladder to the top of each bin
36. 1:35to be emptied and pushed the material
37. 1:37toward the small conveyor at the bottom
38. 1:39of each bin using a shovel.
39. 1:41As the small conveyor belt moved, it
40. 1:44would drop the material onto the larger
41. 1:45conveyor belt.
42. 1:47The material would then be transported
43. 1:49off the end of the larger conveyor belt
44. 1:51and into the trailer of a truck being
45. 1:53operated by a truck driver and would
46. 1:55deliver the materials away from the
47. 1:57site.
48. 1:58The employee and his supervisor had
49. 2:00completed the task of emptying material
50. 2:03from the plant's bins on previous
51. 2:04occasions. Both the small conveyor belt
52. 2:07at the bottom of each bin and larger
53. 2:09conveyor belt running the entire length
54. 2:11of the plant were energized and moving
55. 2:13while the employee was completing this
56. 2:15task.
57. 2:16While the employee was emptying material
58. 2:19from the plant's bins, the supervisor
59. 2:21was in the equipment control room at the
60. 2:23site. This control room, located near
61. 2:26the plant, supplies power to the plant
62. 2:28and other site equipment. From there,
63. 2:31the supervisor monitored the material as
64. 2:33it was transported along the plant's
65. 2:35larger conveyor belt.
66. 2:37After the employee finished emptying the
67. 2:39material from bin four of the plant, his
68. 2:41supervisor turned off the small conveyor
69. 2:43belt under bin four and turned on the
70. 2:45small conveyor belt under bin three so
71. 2:48that the employee could begin emptying
72. 2:49the material from bin three.
73. 2:52Approximately 5 minutes after turning on
74. 2:54the small conveyor belt under bin three
75. 2:56of the plant, the supervisor noticed
76. 2:58that material was no longer running down
77. 3:00the larger conveyor belt.
78. 3:02The supervisor then left the equipment
79. 3:04control room with the plant still
80. 3:06running and went to check in with the
81. 3:07employee. The supervisor climbed a
82. 3:10ladder to reach the top of bin three of
83. 3:12the plant, peered into the bin, and saw
84. 3:14the employee on his side on the small
85. 3:17conveyor belt at the bottom of the bin.
86. 3:19The supervisor observed that the
87. 3:21employee's upper body, including his
88. 3:23head, was covered in material and that
89. 3:26his lower body was uncovered with his
90. 3:28legs bent. The supervisor ran back to
91. 3:30the equipment control room to shut down
92. 3:32the plant and called for first aid
93. 3:34assistance using the two-way radio in
94. 3:36the emergency control room. No one
95. 3:38responded to the two-way radio call. The
96. 3:41supervisor then went back to the plant
97. 3:43and climbed into bin three to extract
98. 3:45the employee from the material. The
99. 3:48employee was unconscious. The supervisor
100. 3:50then ran back to the equipment control
101. 3:52room to call 911. He then provided the
102. 3:55site address to the 911 operator and
103. 3:58asked for an ambulance. The supervisor
104. 4:00returned to the plant and verbally
105. 4:02called out for help from the top of bin
106. 4:04three.
107. 4:05Two contractors from a trucking company
108. 4:07heard the supervisor's call for help.
109. 4:09They went to the plant to meet the
110. 4:11supervisor. The supervisor began
111. 4:13performing CPR on the employee. The
112. 4:16supervisor and the contractor were
113. 4:18unable to successfully resuscitate the
114. 4:20employee.
115. 4:22Another truck driver on site also heard
116. 4:24the yelling and calls for help coming
117. 4:26from the plant. He ran to the plant and
118. 4:28was told to call an ambulance.
119. 4:31The employee then went to the main gate
120. 4:32of the site so he could get the location
121. 4:34of the site for the 911 operator.
122. 4:37Shortly after the police and paramedics
123. 4:40arrived, the police extracted the
124. 4:42employee from bin three of the plant
125. 4:44with the aid of the supervisor and the
126. 4:45contractor who had remained with the
127. 4:48employee inside bin three.
128. 4:50Paramedics performed on-site triage once
129. 4:53the employee was out of bin three of the
130. 4:54plant, but he was soon after declared
131. 4:57deceased by the paramedics.
132. 4:59Since there were no eyewitnesses that
133. 5:01saw how the employee became covered in
134. 5:03material in bin three at the time of the
135. 5:05incident, the specific circumstances
136. 5:08surrounding his death and its exact
137. 5:09cause remain unknown.
138. 5:12Following the incident, the company
139. 5:14implemented a number of corrective
140. 5:16actions, including
141. 5:18A. Placing decals on each side of the
142. 5:21plant's bins stating, "Danger. Do not
143. 5:24enter hoppers."
144. 5:26B. Installing a catwalk on top of the
145. 5:29plant allows safer employee access to
146. 5:31materials in the bins, aiming to reduce
147. 5:34future safety incidents, though it isn't
148. 5:36required by the manufacturer's
149. 5:38specifications.
150. 5:40C. Installing shaker equipment on the
151. 5:43plant, though not required by the
152. 5:45manufacturer, it is intended to safely
153. 5:48and efficiently move material toward the
154. 5:50small conveyor belts at the bin's base.
155. 5:53D. Requiring all employees to attend a
156. 5:554-hour paid safety reorientation.
157. 5:59E. Coaching supervisors on the
158. 6:01importance of reviewing each work
159. 6:03activity in more detail when conducting
160. 6:05hazard assessments and effectively
161. 6:07communicating hazard control measures to
162. 6:09employees on site.
163. 6:11F.
164. 6:12Completing an updated hazard assessment
165. 6:15for the cold bin feed hopper clean out
166. 6:17to change material task, the task the
167. 6:19employee was performing during the
168. 6:21incident, with supervisor involvement in
169. 6:23the assessment process.
170. 6:26G.
171. 6:27Reviewing and updating safety program
172. 6:29materials and safety manuals contained
173. 6:31at the site and ensuring supervisors are
174. 6:33familiar with their contents and how
175. 6:35they can be accessed.
176. 6:38As an additional corrective measure, the
177. 6:39company installed deflector plates in
178. 6:42bins 1, 2, and 3 of the plant to reduce
179. 6:45weight on the small conveyor belts.
180. 6:47Bin 4 already had deflector plates
181. 6:49installed before the incident.
182. 6:52These actions show the company's
183. 6:53commitment to improving safety and
184. 6:55preventing future incidents.
185. 6:58Structural upgrades, new equipment,
186. 7:00clear signage, and employee training
187. 7:03address key risks.
188. 7:05Involving supervisors in hazard
189. 7:07assessments and updating safety
190. 7:08materials further supports a stronger
191. 7:11safety culture.
192. 7:12Together, these steps help reduce the
193. 7:14chance of similar incidents.