2012 fatality report: worker crushed by air handling unit · 6.4 air handling unit components five...
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1 Alberta Human Services, Occupational Health and Safety
WORKER CRUSHED BY AIR HANDLING
UNIT
Type of Incident: Fatality
Date of Incident: November 14, 2012
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File: F-488087
2 Alberta Human Services, Occupational Health and Safety
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 Contractor(s) 3
2.4 Employer(s) 3
2.5 Supplier(s) 3
2.6 Workers(s) 3
2.7 Others 4
3.0 DESCRIPTION OF PRINCIPAL PARTIES 4
3.1 Owner(s) 4
3.2 Prime Contractor(s) 4
3.3 Contractor(s) 4
3.4 Employer(s) 4
3.5 Worker(s) 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 7
8.0 FOLLOW-UP/ ACTION TAKEN 7
8.1 Human Services, Occupational Health and Safety 7
8.2 Industry 8
8.3 Additional Measures 9
9.0 SIGNATURES 10
10.0 ATTACHMENTS 10
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SECTION 1.0 DATE AND TIME OF INCIDENT
1.1 November 14, 2012 at approximately 1:30 p.m.
SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES
2.1 Owner(s)
2.1.1 University of Lethbridge
4401 University Drive West
Lethbridge, Alberta
T1K 3M4
2.2 Prime Contractor
2.2.1 Stuart Olson Dominion Construction Ltd.
6th
Floor, 4838 Richard Road S.W.
Calgary, Alberta
T3E 6L1
2.3 Employer
2.3.1 Zero Gravity Cranes & Rigging Inc.
332 – 36 Street North
Lethbridge, Alberta
T1H 3Z7
2.4 Contractor(s)
2.4.1 K.B. Heating & Air Conditioning Ltd.
3020 – 16 Avenue North
Lethbridge, Alberta
T1H 5E9
2.5 Supplier(s)
2.5.1 Not applicable.
2.6 Worker(s)
2.6.1 The Foreman (***********)
(Names and personal details were removed before distribution of this report.)
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2.7 Others
2.7.1 Constable (**** *******)
Lethbridge Regional Police Service
135 – 1 Avenue South
Lethbridge, Alberta
T1J 0A1
SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES
3.1 The University of Lethbridge is a publicly funded academic and research university
located in Lethbridge, Alberta. It has other campuses in Calgary and Edmonton. The
University of Lethbridge hired Stuart Olson Dominion Construction Ltd. to oversee
construction of Phase 3 of its 259 bed student residences at Aperture Park located at
the southwest corner of the University property.
3.2 Stuart Olson Dominion Construction Ltd. (Stuart Olson) is a progressive builder and
construction management firm with offices in Calgary, Edmonton and Saskatoon.
Stuart Olson is the prime contractor for construction of the student residences. Stuart
Olson is responsible for selecting and hiring sub-trade contractors for various phases
of construction.
3.3 K.B. Heating & Air Conditioning Ltd. (K.B.) is the heating, ventilation and air
conditioning (HVAC) contractor hired by Stuart Olson to supply and install HVAC
equipment.
3.4 Zero Gravity Cranes & Rigging Inc. (Zero Gravity) is a locally owned business
focussed on industrial hoisting and rigging. Zero Gravity employs approximately 20
workers with backgrounds in welding, ironworking, rigging and crane operations.
Zero Gravity was hired by K.B. Heating & Air Conditioning Ltd. to install air
handling unit components and boilers at the student residences.
3.5 The Foreman (***********) was employed by Zero Gravity to oversee a crew
responsible for installation of various types of equipment. The Foreman
(***********) was a journeyman welder and third year apprentice ironworker. The
Foreman (***********) had been employed by Zero Gravity for approximately two
years and had more than ten years of related work experience.
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SECTION 4.0 LOCATION OF INCIDENT
4.1 The incident occurred in the mechanical room located in the southeast corner of the
basement of the north wing of the Phase 3 Aperture Park student residences at the
University of Lethbridge (Refer to Attachment A – Map and Attachment B –
Photographs 1, 2 and 3).
SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS
5.1 Equipment and Material
5.1.1 A McQuay Energy Recovery Wheel, Model ECW 846 (Serial Number
*************) was component 4 of 6 components of an air handling unit being
installed on a concrete pad (pad). Component 4 measured approximately 3.6 meters
long x 0.7 meters wide x 3.0 meters high and weighed 1,242.5 kilograms (Refer to
Attachment B – Photographs 3 to 6 and Attachment C - Drawing).
5.1.2 The pad measured approximately 9.1 meters long x 4.4 meters wide x 0.1 meters high
(Refer to Attachment B – Photograph 5 and 6 and Attachment C – Drawing).
5.1.3 Four employer-fabricated, steel, roller carts (carts) measuring approximately 0.6
meters long x 0.5 meters wide x 0.2 meters high and having a load capacity of 1.36
tonnes were used to move component 4 into the building and into position on the pad
(Refer to Attachment B – Photograph 7).
5.1.4 Two Simplex, Model A 1022, 10-ton (9.07 tonne), mechanical, ratchet jacks (jacks),
stamped 001 and 005 were being used to position component 4 (Refer to Attachment
B – Photograph 8). The jacks were positioned on the east and west corners at the
north end of component 4 (Refer to Attachment B – Photograph 6 and Attachment C -
Drawing).
5.1.5 Plywood squares measuring approximately 0.3 meters long x 0.3 meters wide x 0.02
meters thick were used to support the middle of component 4 while it was being
positioned on the pad (Refer to Attachment B – Photograph 6 and Attachment C -
Drawing).
5.1.6 A single timber measuring approximately 1.2 meters long x 0.1 meters wide x 0.2
meters high was used to support the south end of component 4 during positioning
(Refer to Attachment B – Photograph 6 and Attachment C - Drawing).
5.2 Observations
5.2.1 Component four was narrower than components five and six.
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SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT
6.1 The Employer (************), Worker 1 (************) and Worker 2
(***********) arrived at the Zero Gravity yard and loaded air handling unit
components onto trailers and transported them to the work site.
6.2 Upon arrival at the work site, the Employer (************) spoke to the Stuart
Olsen crane riggers and the Site Superintendent (************). They discussed the
plan for unloading and transferring the air handling unit components into the entrance
of the mechanical room located in the southeast corner of the basement of the north
wing of the student residences.
6.3 The Foreman (***********) arrived at the work site at approximately 9:00 a.m. and
met with the Employer (************), Worker 1 (************), Worker 2
(***********) and Worker 3 (**************) as well as workers from K.B. The
Foreman (***********) conducted a toolbox meeting which included a hazard
assessment for installation of the air handling unit components.
6.4 Air handling unit components five and six were moved into position and permanently
installed on the pad between 9:30 and 11:30 a.m. Due to windy conditions, Zero
Gravity workers then took a lunch break.
6.5 After the lunch break, component four was craned into the door opening, rolled into
the mechanical room on carts and moved onto the pad. This procedure called “jack
and roll” is commonly used by Zero Gravity to install equipment of various shapes
and sizes where other methods such as overhead craning are not feasible.
6.6 At approximately 1:15 p.m., the Foreman (***********) began coordinating the
installation of air handling unit component 4 on the pad with help from Worker 1
(************) and Worker 3 (**************).
6.7 Component four was blocked at the south end with a single timber. The carts were
removed by jacking up component four and installing plywood squares at the center
of the component.
6.8 Worker 1 (************), Worker 3 (**************) and the Foreman
(***********) began final positioning of component 4. Worker 1 (************)
and Worker 3 (**************) raised the jacks at the north end simultaneously
while the Foreman (***********) removed plywood squares at the center. The jacks
were then lowered simultaneously onto the next squares. This process would have
been repeated until one end of component 4 was resting on the pad.
6.9 During final positioning of component 4, jack 001 supporting the northeast corner of
component 4 suddenly dropped. Worker 3 (***************), who was positioned
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7 Alberta Human Services, Occupational Health and Safety
at the northeast corner of the component, said he heard a clink, yelled out a warning
and jumped clear of the falling component. Worker 1 (************) located at the
northwest corner of the component moved off to the side.
6.10 The Foreman (***********) scrambled east from his position at the center of
component four but was unable to clear the falling component. Component four
landed on him, trapping him underneath.
6.11 Worker 1 (************) and Worker 3 (**************), with the assistance of
K.B. workers, lifted component 4 and extracted the Foreman (***********) from
underneath.
6.12 Worker 4 (**********) phoned 911 requesting Emergency Medical Services (EMS).
Worker 6 (*************) came from his work location and initiated first aid. Zero
Gravity workers assisted until EMS personnel arrived.
6.13 EMS took over treating the Foreman (***********). Lethbridge Regional Police
Service (LRPS) arrived shortly thereafter and began an investigation.
6.14 The Foreman (***********) was pronounced deceased at the work site.
SECTION 7.0 ANALYSIS
7.1 Direct Cause
7.1.1 The Foreman (***********) received fatal injuries when component four of an air
handling unit fell on him.
7.2 Contributing Factors
7.2.1 Simplex jack 001 that was supporting the northeast corner of component 4 suddenly
dropped. Engineering tests conducted on Simplex jack 001 showed that it had the
potential for failure (Refer to Attachment D – 10 Ton Jack Mechanical Assessment).
7.2.2 Component four had not been blocked adjacent to the two jacks at the north end of
component four.
SECTION 8.0 FOLLOW-UP/ ACTION TAKEN
8.1 Human Services, Occupational Health and Safety
8.1.1 On November 14, 2012, Occupational Health and Safety (OHS) received an incident
notification, responded to the scene and commenced an incident investigation.
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8.1.2 OHS issued the following orders to Zero Gravity:
Stop work order for positioning of air handling unit components until controls for
potential tip over hazards are developed and workers have been trained in those
control measures.
Stop use of jacks until the employer ensures that they are maintained and
functioning in accordance with the manufacturer’s specifications or specifications
certified by a professional engineer.
8.1.3 OHS issued a Demand to Zero Gravity for copies of information related to the
incident.
8.1.4 OHS also issued the following orders to Stuart Olson:
Stop work order for positioning of air handling unit components as discussed with
Stuart Olson and K.B. representatives until remedial measures are put in place to
prevent a recurrence.
Complete an investigation outlining the circumstances of the accident and the
corrective action undertaken to prevent a recurrence and provide a copy of the
report to OHS.
8.1.5 OHS seized the two Simplex jacks involved in the incident and contracted a third
party mechanical engineering firm to inspect and function test the jacks.
8.2 Industry
8.2.1 Zero Gravity reviewed and amended procedures for the installation of air handling
unit components and future installation of boiler units. A meeting with Stuart Olson,
K.B., Zero Gravity, University of Lethbridge and OHS representatives was held to
review the procedures.
8.2.2 Zero Gravity purchased two new Simplex mechanical jacks and removed all other
Simplex mechanical jacks from service.
8.2.3 Zero Gravity provided all documents demanded along with a copy of their health and
safety program and Certificate of Recognition.
8.2.4 Zero Gravity complied with all orders issued by OHS.
8.2.5 Stuart Olson completed an incident investigation and provided a copy of the report to
OHS for review.
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8.3 Additional Measures
8.3.1 Not applicable.
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SECTION 9.0 SIGNATURES
Original report signed___________ _____________________
(*********), Lead Investigator Date
Original report signed___________ _____________________
(**************), Reviewer Date
Original report signed___________ _____________________
(************), Director Investigation and Mining Date
SECTION 10.0 ATTACHMENTS:
Attachment A Map.
Attachment B Photographs.
Attachment C Drawing.
Attachment D 10 Ton Jack Mechanical Assessment.
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ZERO GRAVITY CRANES AND RIGGING INC. File: F-488087
ATTACHMENT A
MAP
Red arrow shows the location where the incident occurred at the University of Lethbridge,
Phase 3 Aperture Park Student Residences in Lethbridge, Alberta.
Alberta Human Services, Occupational Health and Safety
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ZERO GRAVITY CRANES & RIGGING INC. FILE: F-488087
ATTACHMENT B
PHOTOGRAPH 1 of 8
Photograph 1 - Picture shows the location where the incident occurred – Phase 3 Aperture Park
student residences at the University of Lethbridge. Red arrow designates the north
wing of the residences.
Alberta Human Services, Occupational Health and Safety
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ZERO GRAVITY CRANES & RIGGING INC. FILE: F-488087
ATTACHMENT B
PHOTOGRAPH 2 of 8
Photograph 2 - Green arrow shows the doorway of the mechanical room in the basement that
component four was craned into prior to being positioned on the pad.
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ZERO GRAVITY CRANES & RIGGING INC. FILE: F-488087
ATTACHMENT B
PHOTOGRAPH 3 of 8
Photograph 3 - Shows the mechanical room in the basement of the student residences where the
incident occurred. Red arrow shows the doorway that components four, five and six
were brought through. Green arrow shows components five and six which were
installed prior to the incident. Blue arrow shows component four in its approximate
resting position after the incident.
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ZERO GRAVITY CRANES & RIGGING INC. FILE: F-488087
ATTACHMENT B
PHOTOGRAPH 4 of 8
Photograph 4 – Shows a schematic layout of components one to six of the air handling unit. The
highlighted component four was involved in the incident.
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ZERO GRAVITY CRANES & RIGGING INC. FILE: F-488087
ATTACHMENT B
PHOTOGRAPH 5 of 8
Photograph 5 - Shows component four being recovered after the incident and prior to being lifted into
position on the pad. Blue arrow shows the pad on which all components were to be
placed.
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ZERO GRAVITY CRANES & RIGGING INC. FILE: F-488087
ATTACHMENT B
PHOTOGRAPH 6 of 8
Photograph 6 – Shows the approximate position of component four after it fell.
1. Shows the single timber used to support the south end of component four during
positioning.
2. Shows the pad on which all components were to be placed.
3. Shows plywood squares used to support the middle of component four while it
was being positioned on the pad.
4. Shows the approximate contact position of Simplex jack 001 prior to the incident.
5. Shows the approximate contact position of Simplex jack 005 prior to the incident.
Alberta Human Services, Occupational Health and Safety
1
2
3
5
4
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ZERO GRAVITY CRANES & RIGGING INC. FILE: F-488087
ATTACHMENT B
PHOTOGRAPH 7 of 8
Photograph 7 – Shows two of the four employer-fabricated carts used to move air handling unit
components into the mechanical room located in the basement and into position on the
pad.
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ZERO GRAVITY CRANES & RIGGING INC. FILE: F-488087
ATTACHMENT B
PHOTOGRAPH 8 of 8
Photograph 8 – Shows the Simplex, Model A 1022, 10-ton, mechanical, ratchet jacks involved in the
incident.
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ZERO GRAVITY CRANES AND RIGGING INC. File: F-488087
ATTACHMENT C
DRAWING
Drawing shows the concrete pad with component four of the
air handling unit in position.
Blue arrows show locations of Simplex jacks
Red arrows show locations of plywood squares in the middle of
component four.
Green arrow shows single timber supporting the south end of
component four.
Concrete Pad 4
South Exterior Wall Doorway