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Near Misses

Started by Bill Johnson, May 02, 2001, 01:26:52 PM

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Bill Johnson

I came across these Near Miss Reports on the OFSWA website at http://www.ofswa.on.ca they are good reminders so I thought I'd post some of them.

Chip-n-Saw

What Happened and How?
A worker in a sawmill operation was between the spike rollers of the log turner at the infeed deck attempting to jump the bottom infeed chain back onto the tail end sprocket. He was using a come-along to ease the process. As the chain moved, it activated a photo cell that closes the spike rollers. The rollers closed, pinning and immobilizing the worker in their grip. He suffered only minor puncture marks on his body from shoulders to hips.

Why did this Occur?
The workers in the area believed that their lockout procedures had disabled the spike rollers. However, the power to the solenoid valve that directs the air to the cylinders controlling the operation of the spike roller was still on because another worker was using an air wrench to change knives on the same machine. The main MCC was locked out and the workers mistakenly believed that this would lock out power to the photo cells controlling the spike rollers.

Prevention
Standard operating procedures for must take into consideration all of the components of a particular operation that could become activated while a worker is in the danger zone. Procedures may also need to be revised to consider that workers may engage in more than one maintenance or trouble shooting task on the same equipment at the same time. All workers must be properly trained for the tasks that they are assigned. As well, equipment redesign may be necessary so that separate components can be isolated in their own lock out sequence.

End
Bill

Bill

Bill Johnson

NEAR MISS

IMPROPER USE OF DOZER AND CHAIN IN TOWING!!

What Happened and How?
A dozer operator working on logging road repair was asked to assist in towing a loaded tandem axle log truck that had become stuck in the mud. The dozer operator had never used his equipment for this task before. He fastened a length of 5/16th inch chain from the dozer to the frame of the truck and proceeded to pull the truck out of the mud. The chain tightened as the dozer operator applied more power.

Suddenly the chain broke at the end nearest the truck. The length of broken chain came flying towards the dozer, entered the back of the cab and narrowly missed the dozer operator.


Why Did this Occur?
Upon inspection, the 12 foot length of chain used in this incident had several areas with gouged or stretched links and had no stamped marking indicating the grade of chain. In absence of any stamp, the chain must be considered to be "proof coil grade 3" chain with a working load limit of only 1,900 lbs. Given the weight of the truck, general disrepair and strength of the chain, and the force applied by the dozer, it is concluded that the chain was extended much beyond its working load limit causing it to break. The dozer also had no steel cage protection at the back of the cab that could have stopped the flying chain.

Prevention
Standard operating procedures for towing heavy vehicles must ensure that machines used for towing are properly designed and equipped  for the job at hand.
In this case proper chains in good repair and protective cage would be required.
Workers also must be properly trained for the task they are assigned so that they can recognize the equipment requirements for a particular job, understand safe operating procedures and be able to recognize faulty equipment.

End
Source. Ontario Forestry Safe Workplace Association

Bill
Bill

Bill Johnson

This incident with the chain reminded me of something that happened a while ago.

A bunch of us were out moose hunting one fall, and managed to get one of the trucks stuck in a place where no truck should be to begin with. (But hey we were hunting)
The second truck happened to be a 4X4 so it was decided to just hook the chain up and yank the first one out and carry on. We turned the 4X4 around and backed up towards the truck the was stuck so they were facing tailgate to tailgate and hooked up a piece of chain about 10 feet long.
One of the guys jumped into the 4X4 and stepped on the gas, the chain tightened up and just as it started to take the load it snapped close by the bumper of the stuck truck. The loose chain went flying through the air and punched a hole through the tailgate of the 4X4.
It was only a fluke that the chain didn't clear the tailgate, if it had it would have taken out the back window of the 4X4 and more than likely the driver would have been seriously injured or worse.
The rest of us were pushing the first truck when this happened so luckily were well clear of the flying chain.

After reading the near miss report, I can only guess that the chain we used either wasn't strong enough to do the job or had damaged links in it which we had never even thought to check.

Bill
Bill

Bill Johnson

NEAR MISS

Failure to Properly Secure Parked Skidder on Incline.

What Happened?
An experienced cut and skid team were preparing to cable skid several trees that lay on a moderate slope. Ground conditions were dry. The skidder operator backed down the slope and brought the skidder as close as possible to the trees to be winched. The ground was uneven where the skidder stopped with mounds and hollows on the slope surface.The skidder operator lowered the blade until the left corner of the blade contacted the ground on the high side. He dismounted from the skidder on the right side as the cutter moved to the back of the skidder to begin pulling out the mainline. Just as the operator dismounted, the skidder began to roll backwards. He yelled a warning to the cutter as he attempted to remount the skidder. He lost his footing and fell to the ground. The skidder continued to roll and the operator was dragged under the front right wheel at such an angle the the tire ran over his entire body. He suffered severe multiple injuries.

How did this Happen?
Investigators were not able to determine with certainty whether or not the parking brake was applied. If the parking brake was applied, it was either defective or out of adjustment. There are other important safety factors relating to parking a skidder on and incline as well as dealing with an unmanned moving machine in examining this accident.
First, because of the uneven terrain, the lowered blade was not able to make contact with the ground to such a degree that it would effectively aid in holding the skidder. The blade, which acts as a secondary block to the parking brake should have been firmly applied to the ground with sufficient pressure to assist in holding the skidder. Secondly,  when the skidder started to roll, the operator who had just dismounted and realizing that hes partner was in danger, tried to enter the moving skidder. He slipped and fell under the front wheel as the skidder rolled down the incline. The partner was not injured.

Prevention:
-All workers must receive training, post-training evaluation and follow-up supervision in all aspects of safety training for the work they perform including proper stopping and parking procedures for heavy mobile machines.

-Place decals and signs in the cab warning operators to check that the parking brake is in proper working order and applied whenever leaving the cab.

-Never attempt to mount a moving skidder.

-Use of the blade as a secondary method of securing the machine should be promoted but not depended on exclusively.

End
Source:Ontario Forestry Safe Workplace Association; Near Miss Files.

Bill
Bill

Bill Johnson

Changing Conditions-Changing Hazards
Trucker nearly electrocuted throwing tie down cable

A trucker who had just received a load of 8 foot round wood loaded lengthwise was moving the load to the tiedown area. The area usually set aside for this task was very muddy and the operator feared becoming stuck. He moved several hundred yards further down the road to a wider area and pulled well onto the shoulder of the road to tie down his load. As is common practice, he threw one of the wire cables, weighted on the end by its anchor hook, high into the air and over the load. The free end of the cable sailed over a high voltage power line that ran parallel to the roadway just a few feet from the top and side of the load.

Upon contact with the overhead wire, the operator was knocked to the ground by the electrical current and the truck became energized causing fires in several areas. The operator was saved from serious injury, perhaps, because he was wearing leather gloves and had let go of the tiedown at the last moment.

Why did this occur?
The operator changed the normal pattern of the tiedown process without examining the new circumstances for any hazards they might present.

Prevention:
Always look for new hazards when normal routines are interrupted. All workers must be properly trained for the tasks they are assigned including an awareness of the danger of overhead wires and the need to ensure that minimum distance standards are met. As well, changing conditions that require new procedures should always be checked out by the supervisor to ensure that new hazards do not exist.

Source:OFSWA Near Miss Reports

Bill
Bill

L. Wakefield

   Thank you, thank you! That post is so timely! Hazards exist in all directions- the ones we are most apt to miss are those above us- especially if we are accustomed to a particular area and working room. On fire and rescue calls, we must constantly remind each other of overhead hazards- particularly difficult with calls in the dark. :-/ :-/lw
L. Wakefield, owner and operator of the beastly truck Heretik, that refuses to stay between the lines when parking

Typhoon

Wow... reading that story about the two 4x4's really brought back what happened to me my senior year in high school. I lost a close friend, and I wont go into too many details as there may be someone else reading this that knows him, but if you live anywhere in Southern Illinois, you know about this. But it was the same situation, we were in a rather freshly tilled field, muddy, two 4x4's back to back, I was in the truck that was stuck. I was in the passengers seat. My friend tried to pull us out. The ball came detached from the truck I was in, flew through the back of his truck (a bronco I might add, early model) and hit him dead square in the back of the head. We watched him take his last breath. I have never been able to pull anything of any weight with a chain since that day. Towing big heavy things like vehicles can be VERY dangerous. Hope this helps someone someday.
-Brad
Brad Dawson, Anna IL (Southern tip)
Husky 346xpNE, Husky 357XP, Norwood Lumbermate2000

Bill Johnson

Log Truck Drives Through Stop Sign
Narrowly Missed By Freight Train

What Happened?
After weighing in at a lumber yard, a log truck drove off the weigh scales and proceeded toward a railway crossing.  The truck drove through the railway crossing without stopping and was narrowly missed by on oncoming train.  According to several witnesses, the truck and train would have likely collided if the train had not been slowing down in order to drop off a load of logs at the lumber mill.

Why did it happen?
Unlike level railway crossings on public highways, crossings on logging roads and lumber mill property are generally not equipped with flashing lights, bells or gates.  In this case the crossing had a stop sign, but the truck failed to stop.  The relatively slow speed of the train was the main reason no collision occurred.

How can it be prevented?
After the incident, the lumber company decided to place larger stop signs at the crossing and issued a reminder that all vehicles approaching the railway crossing must come to a complete stop and check for approaching trains before proceeding.  The company also warned that anyone who failed to stop at the crossing would be written up under its health and safety policy.

All log truck drivers should be aware that operators of trains have little of no chance of reacting in time to avoid a collision at a level crossing.  Freight trains can reach speeds in excess of 60 miles per hour and an 88 car train travelling at that speed can take longer than one minute to come to a complete stop.  It's therefore up to the operators of road vehicles to prevent collisions at railway crossings.

To create a more obvious way of alerting drivers to the hazard of private railway crossings, a Northwestern Ontario company has developed a portable battery operated roadside warning system that consists of a continuously flashing red traffic light mounted above a regulation size stop sign.  Firms wishing more information about this system should contact WWS Manufacturing at (807) 879-1173.

END
Bill

Bill Johnson

Rolling Safety Ladder Topples
Maintenance Worker Fractures Pelvis


What Happened?
A maintenance worker with more than five years experience was repairing a clam loader from the platform of a rolling safety ladder in the equipment shop when the loader's hydraulic lift cylinder struck the side of the ladder and tipped it over.  The maintenance worker jumped from the toppling platform at the last second and the right side of his body struck the concrete floor.  He suffered a fractured pelvis and a large cut on his right elbow.

Why did it Happen?
The clam loader was parked in an awkward position in the equipment shop because the clam of another loader was also in the shop for repair.  The rolling safety ladder had to be placed in an unusual position, directly beneath the loader's hydraulic lift cylinder which was supported by an overhead crane.  The lift cylinder was slung at the top and sling was attached to the crane's hook, which wasn't directly above the load.  The crane trolley does not have a braking system to hold it in place horizontally.  Shortly after the maintenance worker removed the pin from the top of the cylinder, the crane was pulled sideways by the weight of the load until it was directly above it.  This movement caused the cylinder to shift downward, striking the railing of the ladder and tipping it.

How can it be prevented?
A worker or a working surface placed directly under a suspended load is in a hazardous position, and the hazard increases if there isn't a clear understanding of have the overhead crane might handle the load.  All operating features of the overhead crane, including limitations such as lack of a horizontal braking system need to be understood and taken into account by the workers involved.  Even a slight sideways lift with an overhead crane can have unpredictable consequences where there is no way of horizontally braking the crane trolley.

A factor that contributed to this incident was that another clam was already in the equipment shop for repairs.  The prevented the clam loader from being parked in the optimum position for maintenance work, and the rolling safety ladder had to be placed in a more vulnerable position in order for the work to be preformed.  A standard operating procedure for this and other similar maintenance tasks should be developed that ensures safe positioning of the machine being worked on and of the working platform from which the work is done.


END
Bill

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