2009 fatality report - worker suffers fatal head crush ... · 10/17/2009 · 5.2.5 a hydrovac...

WORKER SUFFERS FATAL HEAD CRUSH INJURIES Type of Incident: Fatal Date of Incident: October 17, 2009

File: F-569909

TABLE OF CONTENTS

SECTION TITLE PAGE NUMBER

1.0 DATE AND TIME OF INCIDENT 3

2.0 NAME and ADDRESS OF PRINCIPAL PARTIES 3

2.1 Owner 3

2.2 Prime Contractor 3

2.3 Employer 3

2.4 Contractor 3

2.5 Supplier 3

2.6 Worker 4

3.0 DESCRIPTION OF PRINCIPAL PARTIES 4

3.1 Owner 4

3.2 Prime Contractor 4

3.3 Employer 4

3.4 Supplier 4

4.0 LOCATION OF INCIDENT 4

5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5

5.1 Equipment and Material 5

5.2 Observations 5

6.0 NARRATIVE DESCRIPTION OF INCIDENT 6

7.0 ANALYSIS 7

7.1 Direct Cause 7

7.2 Contributing Factors 8

8.0 FOLLOW-UP/ ACTION TAKEN 9

8.1 Occupational Health and Safety 9

8.2 Industry 10

8.3 Additional Measures 10

9.0 SIGNATURES 11

10.0 ATTACHMENTS 11

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August 30, 2010 Alberta Employment and Immigration, Occupational Health and Safety

File: F-569909

SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred on October 17, 2009 at approximately 4:55 p.m. SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES

2.1 Owner 2.1.1 StatoilHydro Canada Ltd. Suite 900 635 – 8 Avenue SW Calgary, Alberta T2P 3M3 2.2 Prime Contractor 2.2.1 IMV Construction Management Inc. 1400, 500 – 5 Avenue SW Calgary, Alberta T2P 3L5 2.3 Employer 2.3.1 Fehr Quality Contracting Inc. Box 71 Conklin, Alberta T0P 1H0 2.4 Contractor Not applicable 2.5 Supplier 2.5.1 Camex Equipment Sales and Rentals Inc. 1511 Sparrow Drive

Nisku, Alberta T9E 8H9 2.5.2 The HydroVac truck that was involved in the fatal incident was leased from Camex

Equipment Sales and Rentals Inc. 2.6 Worker

2.6.1 HydroVac Swamper (Names and personal information have been removed from this report)

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SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3.1 StatoilHydro, based in Norway, is a large integrated technology-based international

company primarily focused on upstream oil and gas operations. StatoilHydro Canada Ltd. currently has over 1100 square km of oil sands leases in Northern Alberta and is developing a 10,000 barrel per day Steam Assisted Gravity Drainage (SAGD) facility northwest of Conklin, Alberta. The project is the Leismere Oilsands Project.

3.2 IMV Construction Management Inc. is a subsidiary of IMV Projects Inc. Both IMV

Construction Management Inc. and IMV Projects Inc. are headquartered in Calgary, Alberta. IMV Projects Inc. specializes in project management, engineering, procurement and construction. IMV Construction Management Inc. was contracted as prime contractor by StatoilHydro Canada Ltd. to manage some areas of the construction of the Leismere Oilsands SAGD Project located 31 km northwest of Conklin, Alberta. IMV Construction Management Inc. held the prime contractor responsibilities for the worksite area where the incident occurred.

3.3 Fehr Quality Contracting Inc. is a small business located in Conklin, Alberta. It

provides vacuum truck service for septic disposal to various camp facilities in the Conklin, Alberta area. Fehr Quality Contracting Inc. was providing septic service, steam truck service and, most recently, HydroVac service to IMV Construction Management Inc. at the StatoilHydro Leismere Oilsands SAGD Project during the construction phase.

3.4 Camex Equipment Sales and Rentals Inc. is a large company that designs and

manufactures oilfield and transportation equipment. Camex Equipment Sales and Rentals Inc. is headquartered in Nisku, Alberta. At the time of the incident, Camex Equipment Sales and Rentals Inc. was manufacturing a custom order HydroVac truck for Fehr Quality Contracting Inc.

SECTION 4.0 LOCATION OF INCIDENT 4.1 The StatoilHydro Leismere Oilsands SAGD Project is located approximately 160 km

south of Fort McMurray on highway 881 and 31 km northwest of the Conklin turnoff. (Attachment A, Map).

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SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS

5.1 Equipment and Material

5.1.1 HydroVac/Steamer Truck 5.1.1.1 Kenworth

Model - T-800 Vehicle Identification # - 1NKDX4EX89R941438 Date of Manufacture - March 2009 (Attachment C, Photograph #1).

5.1.2 HydroVac Tank and Body Assembly 5.1.2.1 Camex

Vehicle Assembly # - 25-392 Serial # - 7382-0812524 Vacuum Tank manufactured by Vacuum Industrial Products Tank Serial # - 09-02105 (Attachment C, Photograph #1) 5.2 Observations 5.2.1 The HydroVac truck involved in the incident was a leased unit and had been

manufactured with the controls for the rear door at the front of the vacuum tank on the operator’s/driver’s side. (Attachment C, Photograph #1)

5.2.2 The rear door of the vacuum tank weighed approximately 421 kg. When fully open

and set to close, the door started at a velocity of 11 kph and ended at the bottom of the closing arc at 35 kph. (Attachment C, Photograph #2)

5.2.3 When a vacuum tank is new, the rear door seal is stiff and does not allow the door to

close tightly. The 6 (six) wing nut tighteners around the circumference at the rear of the tank are engaged and usually tightened from the top to the bottom of the tank to ensure an effective tank seal. Interviews of other truck operators indicated that when the tightening process is almost completed, many operators engage the vacuum pump to suck the door more tightly to the tank and then complete the manual tightening of the door fasteners. (Attachment C, Photograph #3)

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5.2.4 The vacuum truck operators interviewed indicated that their understanding was that if

the wing nut tighteners were not positioned properly when the rear door was closing, they could damage the seal on the vacuum tank and possibly bend and/or break the wing nut assembly. The Occupational Health and Safety Investigators found that the middle and bottom wing nut tighteners on the passenger side of the vacuum tank rear door were positioned in such a way that they would make contact with the rear ring of the vacuum tank when the door closed. (Attachment C, Photograph # 4)

5.2.5 A HydroVac truck has an operator and an assistant called a “swamper”. The

HydroVac truck is a vacuum truck fitted with a hydraulic boom attachment that carries a suction hose. High pressure water from the steamer unit loosens soil, and at the same time the HydroVac hose sucks the loosened soil into the vacuum tank. HydroVacing is often used to expose buried lines without damaging them so that further work may be performed on them.

SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On October 17, 2009 at approximately 6:30 a.m., the Fehr Quality Contracting Inc’s

HydroVac Operator and his Swamper left camp and drove to the StatoilHydro Canada Ltd’s Leismere Project to receive the scheduled work activities for the day. They were sent approximately 2.5 km south of the StatoilHydro Canada Ltd’s SAGD Plant site to complete some HydroVac work to expose a buried grounding grid. They completed a field level hazard assessment for HydroVac work before they started work activities for that day.

6.2 Shortly after 3:30 p.m. they had a full load of mud in their vacuum tank and

proceeded to the dump lagoon that was located just west of the security building at the StatoilHydro Canada Ltd’s SAGD Plant entry. (Attachment A, Map)

6.3 They backed the HydroVac truck into the dump lagoon and proceeded to off-load the

contents of the tank. 6.4 Once the mud was off-loaded, the rear door of the vacuum tank was hydraulically put

in the raised position. The HydroVac Operator and the Swamper took turns pressure washing the interior of the vacuum tank while standing on the beavertails (rear bumper extension platforms) at the rear of the truck.(Attachment C, Photograph #3)

6.5 They finished cleaning the interior of the vacuum tank, and then stepped down from

the beavertails.

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6.6 The HydroVac Operator stated that the Swamper was standing on the ground behind the truck when the Swamper told him to go ahead and close the rear door. The HydroVac Operator proceeded to the controls at the front driver’s side of the HydroVac Truck. (Attachment C, Photograph #3)

6.7 The HydroVac Operator used the controls at the front driver’s side of the HydroVac

Truck to close the rear tank door. 6.8 The Swamper moved onto the right rear beavertail of the HydroVac truck and his

head was caught and crushed between the closing door and the tank. 6.9 The HydroVac Operator noticed something unusual at the rear driver’s side and went

back to inspect. 6.10 The HydroVac Operator found the Swamper lying in the mud at the rear of the truck

unresponsive with a serious head injury. The HydroVac Operator flagged another truck operator from Renegade Gas and Oilfield Services Ltd., who called the StatoilHydro Canada Ltd’s Emergency Services personnel to the site.

6.11 The StatoilHydro Canada Ltd’s Emergency Services Personnel arrived within

minutes and tried to revive the Swamper. They were unable to revive him due to the seriousness of his head injuries and was pronounced dead. The Swamper was removed from the scene by a local area funeral home’s staff.

6.12 The scene of the incident was secured by StatoilHydro Canada Ltd. and IMV

Construction Management Inc. for the Occupational Health and Safety investigation and the incident was reported to Occupational Health and Safety.

SECTION 7.0 ANALYSIS

7.1 Direct Cause

7.1.1 On October 17, 2009 at approximately 4:55 p.m., the Fehr Quality Contracting Inc’s HydroVac Swamper received fatal head injuries as he climbed up onto the passenger-side rear beavertail (bumper extension platform) of the HydroVac Truck at the same time the rear door was being closed. The HydroVac Swamper’s head was caught between the closing door and the rear frame of the vacuum tank. (Attachment C, Photographs #5)

7.2 Contributing Factors 7.2.1 Although the vacuum truck operators had received informal hands-on training on the

operation of the HydroVac truck, none of the vacuum truck operators employed by 7

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Alberta Employment and Immigration, Occupational Health and Safety

File: F-569909

Fehr Quality Contracting Inc. had received any formal training in HydroVac truck operation. There was no operator’s manual available to give instructions on proper procedures to be used for various operations with the HydroVac truck.

7.2.2 The HydroVac Operator had three months experience at operating vacuum trucks

with similar controls, however October 17, 2009 was the first day that the HydroVac Operator had operated the HydroVac Truck. Prior to this, the HydroVac Operator spent only one day as a swamper with HydroVac Operator 2 to learn how to operate the HydroVac Truck. His Swamper was familiar with the operation of the truck as he had worked on the truck as an operator a number of times. The Swamper was acting as a mentor to the new HydroVac Operator on the day of the incident.

7.2.3 There had been no written hazard assessment conducted for the process of off-loading

the mud contained in the vacuum tank, cleaning the vacuum tank interior, and closing up the vacuum tank in preparation for accepting a new load. There was a written Safe Work Procedure for HydroVac Truck operations within the Fehr Quality Contracting Inc. safety program that addressed a verbal check system between the operator and the swamper before the rear door of the HydroVac tank was closed. However, this procedure was never formally communicated nor readily available to the workers involved in this incident.

7.2.4 Although controls for the rear door can be mounted at the rear of the vacuum tank

upon request of the customer, the HydroVac Truck being used at the time of the incident did not have the controls for the rear door operation installed at the rear of the truck. Controls at the rear would have allowed the HydroVac Operator to have visual control of the wing nut tightener positioning and the positioning of his co-worker Swamper when the door was being closed.

7.2.5 The rear door of the HydroVac Truck’s vacuum tank did have a hydraulically

controlled descent to slow down the door closing process, however using the flow restriction control made it impossible to open the door hydraulically. The flow restrictor was set fully open and not being used to restrict flow.

7.2.6 Fehr Quality Contracting Inc. had verbal controls in place to ensure that operators did

not operate equipment until they confirmed that the operation of the equipment would not endanger the health and safety of other workers. However, there were no controls in place for line of sight confirmation before operating the equipment.

7.2.7 The supplier, Camex Equipment Sales and Rentals Inc. did not have any warning

signage at the rear of the vacuum tank indicating the dangers of having any personnel in close proximity to a rear door operation. The HydroVac truck operators were expected to stand on the beavertail before and after the door was closed to tighten and undo the wing nut tighteners on the rear door assembly.

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File: F-569909

7.2.8 When Occupational Health and Safety arrived at the worksite, the middle and bottom

wing nut tighteners on the passenger side of the vacuum tank door were not positioned in the correct latch position (Attachment C, Photograph #4). At the time of the incident, there was no inspection process in place to ensure that the wing nut fasteners were in the correct position before closing the door. While the Camex Equipment Sales and Rentals Inc. Engineer indicated that improper positioning of the wing nut fasteners would not cause damage to the tank rim seal, interviews with other HydroVac truck operators indicated they thought that improper wing tightener positioning on the rear tank would damage the seal on the vacuum tank when the door was closed hydraulically. It is not known if the Swamper noted this and tried to make an adjustment while the rear door was being closed.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN

8.1 Alberta Employment and Immigration; Occupational Health and Safety 8.1.1 Alberta Occupational Health and Safety Officers attended to the site of the incident

and investigated the incident. 8.1.2 The prime contractor, IMV Construction Management Inc., was ordered to complete

an investigation into the incident and prepare a report for review by Occupational Health and Safety detailing the circumstances of the incident and to outline corrective measures to prevent a similar incident.

8.1.3 Fehr Quality Contracting Inc. was ordered to do the following:

- Supply documentation relating to the business, the workers, and the equipment to the Occupational Health and Safety investigators.

- Develop a process whereby operators of vacuum or HydroVac trucks would have visual contact with any workers in close proximity to the equipment while it was being operated.

- Conduct a hazard assessment for the work process of off-loading vacuum/HydroVac trucks where the rear door was being opened and the tank cleaned inside.

8.1.4 Occupational Health and Safety issued Camex Equipment Sales and Rentals Inc. a

stop use order on the HydroVac Truck involved in the incident until an engineer attended the incident site to assess the design and safe operation of the HydroVac Truck’s equipment.

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8.2 Industry 8.2.1 StatoilHydro Canada Ltd. sent a team of investigators from Norway to investigate the

incident. 8.2.2 Fehr Quality Contracting Inc. provided Occupational Health and Safety with

documentation and information related to the incident. They revised their Safe Work Procedure for HydroVac Truck operations to include a visual check to ensure that all workers will stand clear of the rear door and walk around the front of the truck to establish eye contact with the operator before the equipment is operated. They communicated the revised Safe Work Procedure to all their workers though safety meetings.

8.2.2 IMV Construction Management Inc. investigated the incident and produced a report

of the circumstances surrounding the incident and corrective measures to prevent a similar incident. An industry bulletin was produced to share with peer group contractors and other vacuum/HydroVac operators. This bulletin has also been provided to Enform Canada and to the Alberta Construction Safety Association for distribution within their respective industries. All the documentation requested was supplied to the Occupational Health and Safety investigators.

8.2.3 Camex Equipment Sales and Rentals Inc. complied with the order written by

Occupational Health and Safety investigators. As a result of the incident, Camex Equipment Sales and Rentals Inc. have made the following changes to the design of HydroVac trucks that they manufacture:

♦ Warning signs have been installed on the rear sides of the vacuum tank on

the HydroVac Truck (Refer to Attachment “C”, Photograph # 6) ♦ The rear door control lever was moved to the rear of the HydroVac Truck

so the operator would have close visual supervision of any activities during rear door operation. (Attachment “C”, Photograph # 6)

♦ The hydraulic controls for the rear door now have permanent markings on them to provide clear identification for the function of each of the controls (Attachment “C”, Photograph # 7)

♦ Flow restrictors have been installed on the hydraulic return line for the closing of the rear tank door. This slows down the rate of travel when the door reaches the closed position.

8.3 Additional Measures

8.3.1 No additional measures were required. 10

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File: F-569909

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SECTION 9.0 SIGNATURES Original Report Signed______ _____________________ Lead Investigator Date Original Report Signed______ _____________________ Lead Investigator Date Original Report Signed______ _____________________ Investigator Date Original Report Signed______ _____________________ Manager Date Original Report Signed______ _____________________ Regional Director, North Date SECTION 10.0 ATTACHMENTS: Attachment A Map Attachment B Not Applicable Attachment C Photographs

File: F-569909 Attachment “A” Map

Showing Incident Location

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File:F-569909 Attachment “C”

Page 1 of 7

Four hydraulic controls for rear door of hydrovac tank

Shows the Kenworth Truck with the Camex Hydrovac Tank and Body assembly that was involved in the incident. This was the position of the truck during the incident, and when Occupational Health and Safety arrived at the scene. It was backed into a dumping area behind the security building at the entrance to the StatoilHydro Canada Ltd.’s SAGD plant. (see Attachment A, Map) The insert shows the four hydraulic controls for the rear door operation of the HydroVac Truck involved in the incident.

Photograph #1

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Page 2 of 7

The rear door of the tank starts to close at 11 kph.

The rear door of the tanks closes at 35 kph.

The rear door of the hydrovac tank weighs 421 kg.

Shows the rear door of the Hydrovac truck in the open position. The tank door weighs 421 kgs. When the door was set to close by the hydraulic controls at the front of the truck, the door started to close at a speed of 11 kph and reached a speed of 35 kph at the bottom. The red arc in the picture shows the path of travel for the tank door.

Photograph #2

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Page 3 of 7

Photograph #3 Shows the driver’s side of the Kenworth truck and Camex Hydrovac tank and body assembly. The HydroVac Operator was positioned at the rear door hydraulic controls at the time of the incident near the front the truck, while the Swamper was positioned at the rear passenger side of the truck.

This is the location of the hydraulic control levers for the rear door of the hydrovac tank.

These are the platforms that the workers stood on while cleaning the interior of the tank.

This is where the Swamper was standing immediately prior to the door closure.

This is where the Operator would have been positioned when he used the controls to lower the tank door.

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Page 4 of 7

Contact point of middle wing nut fastener and rear of tank.

Contact point of middle wing nut fastener and rear tank.

The top wing nut fastener is in the right position for the latch.

Shows the passenger side view of the hydrovac tank rear door. The inserts are close-ups of the middle and bottom wing nut fasteners position at the time of the incident. As the inserts show, the wing nut fasteners were turned approximately 90 degrees so that they would have come in contact with the tank rim when the door closed and were not in the right position to be latched. The wing nut fastener at the top is turned and in the right position, so that it will not make contact with the door when it closes, and is in the right position to be latched.

Photograph #4

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Page 5 of 7

This is where the Swampers’s head was caught.

Photograph #5

This photograph was taken the on the night of the incident by Occupational Health and Safety Officers. The arrow is pointing to the area of contact where the Swamper’s head was caught between the closing rear door and the rear frame of the hydrovac tank.

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Page 6 of 7

Photograph #6 Shows the driver’s rear side of a hydrovac truck observed at Camex Equipment Sales and Rentals Inc’s facility in Nisku, AB after the incident. This truck has been fitted with the design modifications that the supplier has changed since the incident. The bottom right insert is a close-up of the controls for the operation of opening and closing the tank door. The supplier has moved this control from the front of the truck to this position so that the operator is able to visually verify that all workers are standing clear of the door before it is closed. The top right insert is a close-up of a warning sign that the supplier has installed on the hydrovac truck to warn workers of potential crushing hazards. This sign is also located on the passenger side at the back of the truck.

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Page 7 of 7

Photograph #7 The main photograph shows the hydraulic controls that were used for the operation of the rear door on the hydrovac truck during the incident. The insert shows the new hydraulic controls the supplier has designed and installed on the hydrovac truck. The supplier has moved the controls for the rear door opening and closing and the vacuum shut off valve to different areas of the truck. The supplier has affixed clear and permanent markings to indicate the function of the remaining two controls.

2009 fatality report - worker suffers fatal head crush ... · 10/17/2009 · 5.2.5 a hydrovac...

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