Worker Falls from Trailer Type of Incident: Fatality Date of Incident: January 29, 2009
TABLE OF CONTENTS SECTION TITLE PAGE NUMBER 1.0 DATE AND TIME OF INCIDENT 3 2.0 NAME & ADDRESS OF PRINCIPAL PARTIES 3 2.1 Owner 3 2.2 Prime Contractor 3 2.3 Employer(s) 3 2.4 Contractor(s) 3 2.5 Supplier(s) 3 2.6 Worker(s) 3 2.7 Others 3 3.0 DESCRIPTION OF PRINCIPAL PARTIES 4 3.1 Owner 4 3.2 Employer 4 4.0 LOCATION OF INCIDENT 4 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 4 5.1 Equipment and Material 4 5.2 Observations 4 6.0 NARRATIVE DESCRIPTION OF INCIDENT 5 7.0 ANALYSIS 7 7.1 Direct Cause 7 7.2 Contributing Factors 7 8.0 FOLLOW-UP/ ACTION TAKEN 8 8.1 Occupational Health and Safety 8 8.2 Industry 9 8.3 Additional Measures 9 9.0 SIGNATURES 10 10.0 ATTACHMENTS 10 2 September 16, 2009
SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred on January 29, 2009 at approximately 4:30 p.m. SECTION 2.0 2.1 Owner(s) 2.1.1 JV Driver Corporation Inc. 3601-82 Avenue Leduc, Alberta T9E 0H7 2.2 Prime Contractor 2.2.1 JV Driver Fabricators Inc. 706-25 Avenue Nisku, Alberta T9E 0G6 2.3 Employer 2.3.1 1322286 Alberta Ltd. #106, 4430-106 Street Edmonton, Alberta T6H 4W9 2.4 Contractor(s) 2.4.1 Not applicable 2.5 Supplier(s) 2.5.1 Not applicable NAME AND ADDRESS OF PRINCIPAL PARTIES 2.6 Worker(s) 2.6.1 The Ironworker (Names and personal information were removed before publication of this report) 2.7 Others 2.7.1 Not applicable 3 September 16, 2009
SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3.1 JV Driver Fabricators Inc. is part of the JV Driver Group. JV Driver Fabricators Inc. fabricates structural steel assemblies, pressure vessels, tanks, skids and other equipment at their Nisku facility. 3.2 13222860 Alberta Ltd. is a company owned by The Ironworker. The Ironworker was the company s only employee. 13222860 Alberta Ltd. sub-contracted to JV Driver Fabricators Inc. to provide the services of The Ironworker at the JV Driver Fabricators Inc. Nisku facility. The Ironworker started work for JV Driver Fabricators Inc. on August 25, 2008. SECTION 4.0 LOCATION OF INCIDENT 4.1 The incident occurred at the Mod Yard section of the JV Driver Fabricators Inc. facility, 706-25 Avenue, Nisku, Alberta. (Attachment A Map). SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Material 5.1.1 Hi-Boy flat bed semi-trailer. (Attachment B - Photographs). 5.1.2 The trailer load consisted of steel frames and sections of galvanized steel grating. The top of the load on the trailer at or near where the Ironworker fell from was measured and found to be 3.2 m above ground level. (Attachment B Photographs) 5.2 Observations 5.2.1 A weather data report was obtained from Environment Canada for Edmonton International Airport. Edmonton International Airport is close to the JV Driver Fabricators Inc. Nisku facility. On January 29, 2009 from 7:00 a.m. to 5:00 p.m. the temperature rose from minus 3.3 degrees Celsius to plus 2.9 degrees Celsius. From 7:00 a.m. until noon snow showers were recorded, and from 3:00 p.m. to 5:00 p.m. rain was recorded. 5.2.2 Photographs taken by JV Driver Fabricators Inc. s incident investigators on the day of the incident show that steel frames and gratings forming the top of the trailer load were wet and partially covered with snow. 4 September 16, 2009
SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On the morning of January 27, 2009 the Structural General Foreman for the JV Driver Fabricators Inc. Nisku facility instructed his Foreman to carry out several tasks. One of the tasks was to load materials from a fabrication project onto a flat bed trailer at the Mod Yard. The Foreman allocated the loading task to the Ironworker. The Structural General Foreman was aware of and satisfied with the decision to have the Ironworker take on the task. The Labourer was directed to work with the Ironworker. 6.2 During the morning of January 29, 2009 the Ironworker and the Labourer were working in the Mod Yard carrying out assorted tasks moving and preparing materials for shipping. The trailer loading commenced after the lunch break that ended at 1:00 p.m. The Ironworker was directing the operation. The Labourer was assisting him. An Equipment Operator was operating a zoom-boom vehicle fitted with forks to lift sections of material onto the trailer. A Shipping/Receiving Labourer was checking and recording the piece numbers as the materials were being loaded, moving back and forth between the loading operation and the Shipping Receiving Office as the work progressed. 6.3 As sections of material were loaded, the Ironworker climbed onto the load and placed wooden dunnage to support sections of the load being positioned on top of materials that had already been loaded onto the trailer. After the dunnage was in position the Ironworker would move to the side of the load and signal the Equipment Operator who would then place the next load onto the trailer. 6.4 The Ironworker had a ladder that he used to gain access to the bed of the hi-boy trailer which was approximately 1.5 m above ground level. Once on the trailer bed the Ironworker climbed onto the load, using dunnage sections protruding from the load to access the top of the load. 6.5 The trailer loading proceeded and as more material was added the load on the trailer became higher. The Ironworker climbed on and off the trailer and the load as the work progressed. 6.6 As the work was progressing the weather worsened and turned to rain, heavy at times. The Ironworker and the Labourer were not wearing rain-proof clothing. The Labourer had observed that other workers had rain-proof clothing and asked the Ironworker if wet weather clothing was available. The Ironworker told the Labourer to go to the tool crib and find out. The Labourer left to go to the tool crib. 5 September 16, 2009
6.7 The last section of material was being placed onto the top of the load. The Shipping/Receiving Labourer had been notified and was walking towards the trailer. When the Shipping/Receiving Labourer was approximately 6 m away he saw the Ironworker on top of the load on the trailer. The Shipping/Receiving Labourer called out to the Ironworker that the load was getting too high, and that the work should be shut down. The Ironworker responded that it was OK. The Shipping/Receiving Labourer walked around the south end of the trailer to keep clear of the zoom-boom. 6.8 The Equipment Operator was operating the zoom boom on the east side of the trailer with the last section of the load on the forks, waiting for a signal from the Ironworker. The Ironworker was walking on the top of the load towards the north end of the trailer. The Ironworker slipped and fell from the top of the load onto the ground on the east side of the trailer. The Equipment Operator and the Shipping/Receiving Labourer both saw him fall. 6.9 The Shipping/Receiving Labourer called the JV Driver Fabricators Inc. safety department on his radio to inform them of the incident. The Equipment Operator lowered his load to the ground. The Ironworker was given first aid by the Shipping/Receiving Labourer and by an attendee from the safety department. Emergency Services were called and the Ironworker was transported to hospital. 6.10 The Ironworker suffered non life-threatening injuries and the incident was reported to Workplace Health and Safety by JV Driver Fabricators Inc. as an injury resulting in the worker being admitted to hospital for more than 2 days. The Ironworker suffered complications arising from his injuries and died in hospital on February 13, 2009. SECTION 7.0 ANALYSIS 7.1 Direct Cause 7.1.1 The Ironworker suffered serious injuries as a result of falling approximately 3 m from the top of a load on a hi-boy trailer. The Ironworker subsequently died as a result of complications arising from the injuries he sustained from the fall. 7.2 Contributing Factors 7.2.1 It had been raining at the site before the incident. The load and the ground were wet. Photographs taken by JV Driver Fabricators Inc. after the incident showed that the top of the load was wet and that there was some snow on parts of the load. 7.2.2 JV Driver Fabricators Inc. had a Fall Protection Program. The Program required workers to use a fall protection system where a fall from 3 m or more may occur. The Ironworker had received a safety orientation that included the Fall Protection Program. The Ironworker had also signed a sub-contractor agreement that stated 6 September 16, 2009
This is a 100% tie-off site and all employees working above 3 meters must be tied off at all times. On the day of the incident the Ironworker had signed onto a Supervisor s Pre-Job Hazard Assessment that identified falling as a hazard and required 100% tie-off as a control measure. 7.2.3 The 3 m height above which workers must be tied off is a statutory requirement. Occupational Health and Safety Investigators took measurements and found that there was some variation in the height of the top of the load. The Ironworker was near, at or just above the statutory height limit of 3 m when he fell. There was no tie-off point above the trailer at the time of the incident, but there was equipment on site that could be brought to the workplace and used to provide a tie-off point where required. (Serious injuries can and do occur where workers fall from less than 3 m high). 7.2.4 The weather was poor, the workers were wet from the rain, the work day was almost over and the workers were placing the last section of the load when the incident occurred. 7.2.5 JV Driver Fabricators Inc. had safety management procedures that required toolbox safety meetings to be conducted by Supervisors at the beginning of each shift. After the Supervisor s safety meeting a 100% Safe open forum meeting is held by each foreman and his crew. Following this meeting all workers sign off that they will complete a Driver Safety Card specific to the tasks they will be working on that day. These procedures were followed on the day of the incident. 7.2.6 JV Driver Fabricators Inc. had a safety management procedure called Driver Safety Cards. The JV Driver Safety Handbook, which was given to all workers during their orientation, described the use of the Driver Safety Cards. Workers were required to use Driver Safety cards to report near-miss incidents and to complete a Driver Safety Card for any routine work not requiring a Hazardous Work Permit. It was found that the Equipment Operator and the Shipping/Receiving Labourer had both signed onto Driver Safety Cards that had been prepared for their work groups. However, the Ironworker and the Labourer had not signed onto a Driver Safety Card, and the four workers involved in the task of loading the trailer had not completed or signed onto a Driver Safety Card that covered the work they were all doing together. 7 September 16, 2009
7.2.7 During the morning of the day of the incident the Labourer and the Ironworker had been carrying out tasks in the Mod Yard including moving sections of steel. The Labourer became concerned about the safety of the work. The Labourer discussed his concerns several times with the Ironworker. The Labourer had worked for JV Driver Fabricators Inc. for less than a week. During the morning coffee break the Labourer talked to other workers and was advised that he should complete a Driver Safety Card in order to have any safety problems taken care of. The Labourer completed a Driver Safety Card describing his concerns, but he had not handed in the Driver Safety Card before the incident occurred. SECTION 8.0 FOLLOW-UP/ ACTION TAKEN 8.1 Employment and Immigration; Occupational Health and Safety 8.1.1 Occupational Health and Safety commenced a full investigation after notification was received that the Ironworker died on February 13, 2009. 8.1.2 Occupational Health and Safety issued Compliance Reports to JV Driver Fabricators Inc. confirming receipt of documentation and information requested from them as the prime contractor. 8.1.3 Occupational Health and Safety investigators examined the trailer and load that had been left undisturbed at the scene following the incident. 8.2 Industry 8.2.1 JV Driver Fabricators Inc. provided Occupational Health and Safety with a copy of their completed incident investigation report. 8.2.2 JV Driver Fabricators Inc. reviewed their fall protection procedures following the incident. As a result of the review JV Driver Fabricators Inc. implemented revised procedures, including a fall protection rule required when working at a height greater than 2 m (6 feet). 8.2.3 The JV Driver Group prepared an Intervention Video to promote and encourage interventions in a positive way by workers who observe possible safety issues. The video explains how to intervene effectively and respectfully. The video will become part of the JV Driver Group safety training systems. 8 September 16, 2009
8.2.4 The JV Driver Group initiated new training to encourage workers to adopt a healthy lifestyle and to encourage workers to inform the employer of any pre-existing medical conditions that they may have, that may impact health and safety or impede their ability to recover following a workplace injury. 8.2.5 The JV Driver Group contacted the Alberta Construction Safety Association to lobby for a 2 m (6 feet) fall protection rule to be accepted as best practice in construction. 8.2.6 The JV Driver Group will establish a scholarship fund in the name of the fatally injured worker to assist tradespeople with costs associated with technical training. The scholarship will be open to bargaining unit members and awarded annually. 8.3 Additional Measures 8.3.1 No additional measures were required. SECTION 9.0 SIGNATURES Original Report Signed Lead Investigator Original Report Signed Investigator Original Report Signed Manager Original Report Signed Regional Director Date Date Date Date SECTION 10.0 Attachment A Attachment B ATTACHMENTS: Map Photographs 9 September 16, 2009
Attachment A Map Showing Incident Location
Attachment B Photographs Page 1of 4 Photograph #1 Shows the west side of the trailer.
Attachment B Photographs Page 2 of 4 Photograph #2 Shows the south end of the trailer.
Attachment B Photographs Page 3 of 4 Photograph #3 Shows the east side of the trailer. Arrow indicates the approximate location of the Ironworker before he fell. (The stepladder had been placed in position after the incident)
Attachment B Photographs Page 4 of 4 Photograph #4 Shows a close-up view of the section of the load. Arrow shows the approximate location of the Ironworker before he fell.