Worker Crushed by Vessel Date of Incident: August 3, 2007 Type of Incident: Fatal

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1 Worker Crushed by Vessel Date of Incident: August 3, 2007 Type of Incident: Fatal

2 TABLE OF CONTENTS SECTION TITLE PAGE 1.0 DATE AND TIME OF INCIDENT NAME & ADDRESS OF PRINCIPAL PARTIES Employer Worker DESCRIPTION OF PRINCIPAL PARTIES Employer Worker LOCATION OF INCIDENT EQUIPMENT, MATERIAL AND OBSERVATIONS Equipment and Material Observations NARRATIVE DESCRIPTION OF INCIDENT ANALYSIS Direct Cause Contributing Factors FOLLOW-UP/ ACTION TAKEN Workplace Health and Safety Compliance Industry Additional Measures SIGNATURES ATTACHMENTS 10 2

3 File: F SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred on August 3, 2007 at approximately 9:40 a.m. SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES 2.1 Employer Bromley Mechanical Services Inc., rd Street SW Medicine Hat, Alberta T1A 7G2 2.2 Worker Spotter 2 (Names and personal details were removed before distribution of this report) SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3.1 Bromley Mechanical Services Inc., a Division of Argo Sales Ltd. specializes in custom manufacturing of oil and gas facilities. The original company was founded in 1942 and acquired by Argo Sales Ltd. in The worker Spotter 2 was a welder with Bromley Mechanical Services and was employed since August 23, His job duties included working in the welding shop, welding on vessels and assisting with material lifts. 3.3 The overhead crane operator was also a welder for Bromley Mechanical Services. He has been employed by the company since September 8, 1997 and has been the shop foreman for the last five years. He holds a Certificate of Completion from the Manufacturers Health and Safety Association for the Overhead Crane Training Program and Basic Rigging Safety Course. He was considered to be the overhead crane trainer in the shop. SECTION 4.0 LOCATION OF INCIDENT 3

4 File: F The incident occurred in the welding shop of Bromley Mechanical Services, located at rd Street SW in Medicine Hat, Alberta (Reference Attachment A, Map; Attachment B, Photograph 1 and Attachment C, Diagram 1). SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Material A P&H 30 ton overhead crane was involved in the incident and it was one of three overhead cranes operating in the welding shop. This overhead crane was located in the middle of the shop with a smaller overhead crane on each end (Reference Attachment B, Photograph 2) The Brenergy vessel that was being lifted was 1.8 meters in diameter and 6.6 meters in length. This vessel weighed approximately 8,600 kilograms. This vessel was fabricated on rollers on the floor so the vessel could be rolled for easier welding. When the welding on the vessel was completed slings were installed on each end of the vessel to lift it off the rollers and set it on the floor. The slings were positioned off center to the side of the vessel so when the vessel was lifted vertically by the overhead crane, the vessel was allowed to rotate onto its legs on the concrete floor (Refer to Attachment B, Photographs 3 and 4) The Aristar vessel was a stationary vessel located on the floor that was 1.5 meters in diameter and 6 meters in length. This vessel weighed approximately 12,000 kilograms (Reference Attachment B, Photographs 2, 3, 4, 5, 6, and 7) After the incident the overhead crane was examined by an engineering firm and found to be structurally sound. However, the engineer expressed concerns over significant delays between the execution of a signal and the stopping of the bridge. The overhead crane was equipped with directional signage under the girder beam which was used to identify the direction of travel (Reference Attachment B, Photographs 2 and 8) The remote control for the overhead crane was in use at the time of the incident. This precaution was taken in order to remove workers from the lift area. The direction control buttons on the remote control for down and north were side by side. The remote control was examined by an engineering company after the incident and found to be in good operating condition (Reference Attachment B, Photograph 9) The pendulum control for the overhead crane was not in use at the time of the incident. The engineering report indicated that both the pendulum and the remote control were functional (Reference Attachment B, Photograph 10). 4

5 File: F Observations The weather conditions were warm and sunny on the day of the incident. The incident occurred inside the welding shop which was well lit. The large sliding doors were open on each side of the welding shop. The Medicine Hat Police Service had secured the scene with barrier tape and had an Officer at the scene to prevent access. The trolley on the overhead crane had the hook and load line attached to slings on the vessel. The load line was on an angle with the trolley heading in the north direction. SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On August 3, 2007 an overhead crane operator and three workers employed as Spotters. (Spotter 1, Spotter 2 and Spotter 3) started the critical lift of a vessel fabricated on rollers in the welding shop. The slings were installed on the vessel with the lifting points off center to the north side of the vessel. 6.2 The overhead crane operator was located on the north side of the vessel. Spotter 1 was positioned on the east side of the vessel, Spotter 2 was positioned on the south side of the vessel and Spotter 3 was positioned on the north side of the vessel near the crane operator. 6.3 The overhead crane operator used the remote control to operate the overhead crane and hoisted the vessel. The overhead crane operator then allowed the vessel to rotate and set the vessel on the floor on its legs. Spotter 2 approached the vessels and entered the area between the stationary vessel and the vessel being hoisted. 6.4 The overhead crane operator pressed a button to lower the hook to allow slack in the slings. However instead of lowering the hook, he inadvertently pressed the north button instead of the down button. This caused the overhead crane and the hoisted vessel to move towards the stationary vessel. The hoisted vessel struck the stationary vessel and crushed Spotter 2 who was standing between the two vessels. 6.5 Spotter 2 was attended immediately by co-workers. Emergency Medical Services was called and Spotter 2 was transported to the Medicine Hat Hospital where he was pronounced dead. SECTION 7.0 ANALYSIS 5

6 File: F Direct Cause Spotter 2 received fatal injuries when he was crushed between the hoisted vessel and the stationary vessel. 7.2 Contributing Factors The overhead crane operator moved the overhead crane and hoisted the vessel towards the stationary vessel instead of lowering the hook and sling. There was no clear communication between the overhead crane operator and Spotter 2 to establish safe working conditions prior to the next step during the hoisting of the vessel. The completed hazard assessment did not identify the potential hazard of crush injury during hoisting of vessels. Control measures were not in place to eliminate the hazard. SECTION 8.0 FOLLOW-UP/ACTION TAKEN 8.1 Employment, Immigration and Industry; Workplace Health and Safety Compliance (WHSC) WHSC received an incident notification on August 3, 2007 at 10:00 a.m., responded to the scene, and commenced an incident investigation The employer was requested to secure the scene until WHSC arrived on site. Medicine Hat Police Service was on site and secured the scene WHSC issued the following orders to Bromley Mechanical Services Inc.: A Stop Use Order was issued regarding the P&H 30 ton overhead crane and the remote control device for the overhead crane until certified by a professional engineer. A Stop Use Tag #4258 was placed on the P&H 30 ton overhead crane. An order for a hazard assessment to identify existing or potential hazards at the work site. The existing overhead crane and rigging/slinging hazard assessment did not specifically identify the potential hazards in regard to crush injuries and safe locations for installing, repositioning or removing slings. An order requiring that all workers involved in overhead crane operations must be trained in the safe operations of the overhead cranes. Employer must ensure workers receive training on the new hazard assessment and hazard control methods. An order was issued requiring the employer to conduct an incident investigation and 6

7 File: F prepare a report outlining the circumstances surrounding the incident, as well as preventative measures On August 3, 2007 WHSC requested the employer to provide a copy of documents regarding hazard assessments for rigging, slinging and overhead cranes, drawings for the two vessels involved in the incident, recent inspection report for the P&H 30 ton overhead crane, training and certifications for crane operator, safety orientation and employee information for deceased worker WHSC requested that the employer conduct a safety meeting prior to work commencing on August 7, 2007 to provide an update on the incident and instruction to workers on overhead cranes in regard to rigging and slinging hazards On August 7, 2007 WHSC attended a meeting at the employer s office. The incident was reviewed and preventive measures were discussed On August 7, 2007 WHSC requested that the employer develop a written procedure to move the vessel from the incident location to a safe area and to store the crane until it could be examined by a professional engineer and re-certified On September 14, 2007 WHSC received notification from the employer that the overhead crane was inspected by a professional engineer and found to be in good working condition. A copy of the engineering report was received On September 17, 2007 WHSC conducted a follow up site visit to review compliance with the issued orders. The Stop Use Tag was removed from the overhead crane. The overhead crane was required to be operated from the pendulum control. Additional information was requested on hazard assessment and hazard controls in regard to defining critical lifts and specialized rigging On November 6, 2007 WHSC conducted a follow up inspection and requested additional engineering information on the remote control for the overhead crane. 8.2 Industry On August 3, 2007 after the incident, Bromley Mechanical Services Inc. voluntarily stopped work and commenced an incident investigation. The scene was then secured by the Medicine Hat Police Service until WHSC arrived on site On August 3, 2007 Bromley Mechanical Services Inc. provided a copy of documents requested by WHSC as follows; hazard assessments for rigging, slinging and 7

8 File: F overhead cranes, drawings for two vessels involved in the incident, recent inspection report for P&H 30 ton overhead crane, training and certifications for overhead crane operator and safety orientation On August 7, 2007 Bromley Mechanical Services Inc. provided a copy of the minutes for a Safety Meeting which was held on August 7, 2007 prior to workers commencing work On August 7, 2007 Bromley Mechanical Services Inc. provided a written procedure to move the vessel from the incident location and to provide safe storage for the overhead crane until it could be examined by a professional engineer and re-certified Bromley Mechanical Services Inc. hired a professional engineer to inspect the overhead crane after the incident. It was certified to be in good working order Bromley Mechanical Services Inc. investigated the incident, prepared a report, and submitted it to WHSC for review Bromley Mechanical Services Inc. revised their Hazard Assessment document to specifically identify crush hazards and control measures. This information was reviewed with workers at a meeting on September 17, On October 17, 2007 Bromley Mechanical Services Inc. provided revised documents on Hazard Assessment for Overhead Cranes and a Critical Lift Toolbox Meeting Checklist. The documents addressed the Client Contact Report request for additional information made on September 17, On November 6, 2007 Bromley Mechanical Services provided an inspection report prepared by Sintra Engineering Inc. on the overhead crane and the remote control device. The report indicated that the overhead crane and remote control device were in good working conditions The employer complied with all orders issued. 8.3 Additional Measures The Argo Sales Ltd. has another facility where the preventive measures were also instituted. 8

9 File: F SECTION 9.0 SIGNATURES Original Report Signed Lead Investigator Date Original Report Signed Reviewer Date Original Report Signed Regional Senior Manager Date SECTION 10.0 ATTACHMENTS Attachment A Map Attachment B Photographs Attachment C Diagram 9

10 Attachment A Map Location of incident Bromley Mechanical Services rd Street SW Medicine Hat, AB

11 Bromley Mechanical Services Inc., File: F Attachment B Photograph 1 of 10 Photograph 1: Shows Bromley Mechanical Services Inc., A Division of Argo Sales Ltd. located at rd Street SW in Medicine Hat, Alberta.

Bromley Mechanical Services Inc., File: F- 114560 Attachment B Photograph 2

12 Bromley Mechanical Services Inc., File: F Attachment B Photograph 2 of Photograph 2: Shows an overview of the incident scene, looking to the east. 1. The P&H 30 ton overhead crane 2. Brenergy vessel being hoisted 3. Point of impact for vessels 4. Aristar vessel stationary

Bromley Mechanical Services Inc., File: F- 114560 Attachment B Photograph 3 of 10 1. 2. 3. 4. 5. 6.

13 Bromley Mechanical Services Inc., File: F Attachment B Photograph 3 of Photograph 3: Shows a closer view of the incident scene, looking to the east. 1. The P&H 30 ton overhead crane 2. Hoist line and hook 3. Slings on vessel with lifting point off center

4. Location of Spotter 2 during the lift 5. Path of travel of Spotter 2 6. Location of incident, point of impact Bromley Mechanical Services Inc., File: F- 114560 Attachment B Photograph 4 of 10 1. 2. 3.

14 4. Location of Spotter 2 during the lift 5. Path of travel of Spotter 2 6. Location of incident, point of impact Bromley Mechanical Services Inc., File: F Attachment B Photograph 4 of Photograph 4: Shows where the vessel was fabricated on the rollers. 1. The Brenergy vessel that was being lifted 2. Slings in position around the vessel 3. Rollers on which the vessel was fabricated 4. Location of Spotter 2 during the lift 5. Approximate path of travel of Spotter 2

Bromley Mechanical Services Inc., File: F- 114560 Attachment B Photograph 5 of 10 1. 2. 3. 4. 7. 6. 5. Photograph 5: Shows the incident scene looking to the west. 1. Overhead crane hook 2.

15 Bromley Mechanical Services Inc., File: F Attachment B Photograph 5 of Photograph 5: Shows the incident scene looking to the west. 1. Overhead crane hook 2. Slings on vessel with lifting points off center 3. Position of Spotter 2 at time of incident between vessels 4. Point of vessel contact 5. Location of crane operator and Spotter 3 6. Aristar stationary vessel 7. Brenergy vessel being hoisted

Bromley Mechanical Services Inc., File: F- 114560 Attachment B Photograph 6 of 10 1.

16 Bromley Mechanical Services Inc., File: F Attachment B Photograph 6 of Photograph 6: Shows the Brenergy vessel looking east. 1. The mark on the concrete floor was approximately 1.2 meters created when the vessel was dragged.

Bromley Mechanical Services Inc., File: F- 114560 Attachment B Photograph 7 of 10 1.

17 Bromley Mechanical Services Inc., File: F Attachment B Photograph 7 of Photograph 7: Shows the Brenergy vessel looking north. 1. The mark on the concrete floor was approximately 2.1 meters created when the vessel was dragged.

18 Bromley Mechanical Services Inc., File: F Attachment B Photograph 8 of 10 Photograph 8: Shows the directional signage under the girder beam of the overhead crane.

Bromley Mechanical Services Inc., File: F- 114560 Attachment B Photograph 9 of 10 6. 7. 8. 9. 10. 5. 4. 3. 2. 1. Photograph 9: Shows the remote control being used at the time of the incident by the overhead crane operator.

19 Bromley Mechanical Services Inc., File: F Attachment B Photograph 9 of Photograph 9: Shows the remote control being used at the time of the incident by the overhead crane operator. Overhead crane operator (***************) accidentally pushed the north button (9) instead of the down button (8). 1. On 2. Speed 1 3. South 4. Up 5. East 6. Emergency Stop

7. West 8. Down located close to north button 9. North located close to down button 10. Speed 2 Bromley Mechanical Services Inc., File: F- 114560 Attachment B Photograph 10 of 10 1. 2. 3.

20 7. West 8. Down located close to north button 9. North located close to down button 10. Speed 2 Bromley Mechanical Services Inc., File: F Attachment B Photograph 10 of Photograph 10: Shows the pendulum control for the overhead crane, which was not in use at the time of the incident. 1. West 2. East 3. South 4. North 5. Down 6. Up 7. Horn

21 8. Emergency Stop

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