Date: 8 February 1995
Subject: Log Loader Runs Over Worker at Stave Mill
A 56 year-old-male stave edger was killed when he entered the
path of a moving log loader at a saw mill. At 4:30 pm the day
of the incident, the victim had completed an 8-hour shift in the
mill. He walked out of the metal building toward the employee
parking area. About 18 feet from the building he was struck by
a loader, which was backing up. A witness and the loader driver
ran to the victim and helped move him to some nearby logs. The
victim was alive and conscious. He removed his ear plugs while
waiting for the ambulance to arrive. First aid was administered
at the scene by a physician, who was on the premises at the time.
The victim was transferred by ambulance to the local hospital
and subsequently air-lifted to a major medical center 70 miles
away. He lived seven days, then died of acute cardiovascular collapse
during surgery. The FACE investigator concluded that in order
to prevent future fatalities of this type, saw mill owners and
On 17 November 1994, a 56-year-old male saw mill worker was injured
when he was run over by a log loader. On 23 November 1994, the
victim died in the operating room as a result of the injuries
sustained in the run over. On 25 November 1994, the FACE investigator
read of the incident in the newspaper and on 29 November 1994,
the FACE investigator, along with a KY OSH compliance officer
traveled to the scene. The company owners (3) were interviewed.
The log loader driver, EMS personnel and the physician at the
scene were all interviewed. An equipment dealer and manufacturer's
representative were consulted regarding the case. Photographs
of the scene and related equipment were taken and sound level
measurements made. A copy of the OSH compliance report and death
certificate were later reviewed. The Kentucky Department of Forestry
and the Forestry Department at the University of Kentucky were
consulted about the incident.
The family-owned saw mill has been in business at this location
since 1976. This vertically-integrated, whiskey barrel manufacturer
employs between 40 and 45 full-time workers. White oak logs are
delivered to the site by independent log cutters. They are unloaded,
debarked and cross-cut to 3' lengths. These segments are then
halved and quartered. Band saws are then used to cut the quarters
into 1" thick staves. The staves are then edged to random
widths. This process continues 8 hours per day inside a metal
building where 12 employees keep the line running. The staves
are then stacked and taken to a kiln for drying. Once dried, barrels
are constructed and the inside char-burned. Three hundred barrels
are completed for quality testing per day. Finished products are
sold to distilleries. The company employs three other workers
with similar responsibilities as the victim.
Safety meetings are conducted quarterly with all employees. Topics
include eye protection, first aid, universal precautions, material
safety data procedures, hearing protection and others. All new
hires complete an orientation/training period where safety issues
are discussed. The company owner is in charge of safety training
and safety oversight. The employer provides ear plugs and eye
protective equipment for all its workers. Individual position
training is largely on the job. The OSHA 200 Log was current and
reflected few reportable injuries. This was the second fatality
at the site. Approximately 4 years prior, a logging contractor
was killed when a log above the bolsters rolled off his truck
and struck him.
The victim had worked for the company for 22 years. He had completed
the same task as a stave edger for several years. Safety training
courses were regularly attended by the victim and the loader driver.
The victim's health was fair and co-workers reported he was a
very active hunter and had other physical pursuits. He had been
a heavy smoker but had quit one year prior to the incident. All
employees on the line wore eye and ear protection on the day of
the investigation. Tapered foam earplugs (noise rating 31 dBa)
are provided by the employer. Routine hearing evaluations were
not a part of the employer's health screening and therefore assessment
of the victims hearing was not available. The employer reports
that audiometric tests are now a part of the company's safety
and health practices.
This manufacturer specializes in using white oak logs to make
whiskey barrels. It covers a 12 acre site where logs are delivered,
stacked and then processed. Several buildings including a mill,
a kiln, an office, an assembly plant and equipment storage sheds
dot the land. The victim was assigned to work in the mill. He
was to take staves on the assembly line and trim the edges to
random widths. The job is performed standing and involves manual
manipulation of rough sawed pieces through a band saw. Work is
performed is inside a 50 x 90 metal building where the logs enter
one end and rough sawn barrel staves and bottoms come out the
other end. Two band saws, two circular saws, one circular cut
off saw and a conveyer operate eight hours a day inside the mill.
Noise measurements taken the day of the investigation were between
96 and 100 dBa near work stations inside the mill.
The equipment involved in the incident was a 3 year old Kawasaki
60Z II, 4-wheel drive (103 hp) log loader. This 18,000 pound loader
was equipped with lift forks but no grippers. Its fluid-filled,
17.5 x 25 tires were on 8' 8" centers. The overall unit height
was 10' 1". It was equipped with glass-enclosed ROPS and
three convex mirrors, two mounted outside on the right and left,
and one inside in the center. On the day of the investigation,
the windows were clean. Reports from the employer indicate the
unit's windows are cleaned prior to every shift. The liquid-cooled
axle brakes functioned properly on the day of the investigation.
A 24-volt, factory installed, audible back-up warning device (107
dBa rating) was working the day of the investigation. The horn
operated by the driver worked on the day of the investigation
as well. When checked by the investigator, the audible signal
measured 93 dBa six feet from the unit. According to the manufacturer,
without modifications, the log loader operates at 82-85 dBa. This
level was confirmed the day of the investigation.
A chipper sits about 40 feet from the mill. Scraps are delivered
to the chipper several times per day using a log loader. The chipper
operates at 110 dBa at the work station and about 100 dBa 15 feet
from the unit.
At 4:30 pm on the day of the incident, the sky was overcast, the
temperature about 50 degrees and the victim had just completed
his shift in the mill. The assembly line had been shut down for
the day. Talks with co-workers earlier in the day led them to
believe the victim was going hunting that evening. He walked out
of the wide door at the mill entrance and preceded about 18 feet
toward the employee parking lot. He was hit and run over by the
log loader which had just dropped a load of scraps at the chipper
and was backing up to turn around. The driver reported he could
not hear the back-up alarm because of the combined noise of the
loader and the chipper, but that under most circumstances he could
hear the device. Most of the victim's co-workers were still in
the building at the time of the incident. However, the incident
was witnessed by a contractor who was sitting in his truck parked
near the building at the time.
The loader driver did not see or hear the victim. He had been
employed by the company 10 years in the same position and was
noted for his safety consciousness regarding the log loader. It
is estimated the loader was backing up at a rate of 8-10 mph.
Noise inside the cab was measured at 80 dBa the day of the investigation.
The victim was helped to a stack of logs by the driver and the
witness. While sitting/leaning upon some logs, the victim removed
his earplugs. He was treated for shock by a physician on the grounds
and 911 was called, with EMS arriving minutes later. The victim
was transferred to area hospital and later to larger medical center.
He lived five days and died in the operating room at 7:16 pm on
23 November 1994, of acute cardiovascular collapse.
CAUSE OF DEATH
The victim died of as a result of injuries sustained in a log loader run over. Injuries included fractured pelvis, femur, hip, acetabulum, and an L-1 compression fracture.
Recommendation #1: Instruct employees to remove ear plugs
when a leaving high noise area. Courses on hearing protection
should also be offered.
Discussion #1: In this case it is thought that the victim
did not hear the audible warning device as he left the mill. Assuming
the device worked the day of the incident, it is possible that
after working an 8 hour shift where the noise is attenuated 31%
by the foam ear plugs, then walking outside where the chipper
whined at over 95 dBa, it is possible that the victim did not
hear the device. Co-workers suggested that inattention was a factor
because the victim was excited about going hunting that evening.
However, if he had removed his ear plugs as he exited the building,
the victim may have noted the back up alarm and moved out of its
Safety training courses offered by the employer should include
noise and hearing conservation. The one hour Employee Training
For The Hearing Conservation Amendment course offered by Kentucky
OSH Education and Training Services would satisfy the annual training
requirements for those employees exposed to noise in excess of
85 dBa for an eight hour time weighted average. Although an eight
hour sample was not taken, spot measurements in the mill were
between 93 and 100 dBa. Therefore, training is recommended. Included
in the training should be instructions on when to remove personal
protective equipment to avoid injury.
Recommendation #2: Install the loudest possible back up
warning device, visible signals, such as a rotating beacon should
be added to equipment which is routinely operated in a noisy environment.
Discussion #2: After-market warning devices are available
from equipment dealers and, if installed, would increase notification
to employees of potential hazards. Although the unit was equipped
with an adequate audible warning device per OSHA 1910.265(c) (30)
(ii) and it was in operable condition, it may not have been audible
above the surrounding noise level. The noise of the high-pitched
chipper may have exceeded the sound of the back up warning device
on the day of the incident. Measurements taken with a Brhel
and KjFr Precision
Sound Level Meter Type 2232 showed environmental noise (from all
sources) at around 85 dBa. Adjustable Audio Warning Devices are
available as after-market products for this machine. The cost
is about $97.00 per unit. These units are adjustable between 97
and 112 dBa.
Visible warning devices, suggested by OSHA 1910.165 Appendix A -2. for physically impaired individuals, which operate on a 12 volts, are available as after market products from equipment dealers. These rotating beacon or strobe lights would offer a visible warning signal, alerting employees in the vicinity. The cost is about $125.00 for a strobe and $75.00 for a rotating light. These units are magnetically mounted and operate on a 12-volt system.
Recommendation #3: A safety training course on the log
loader should be offered. Safe operating procedures and hazard
recognition should be a part of the course.
Discussion #3: As part of the quarterly safety meetings,
information on the hazards of log loaders may have alerted the
victim to the potential danger of the log loader. Routine safety
training for loader drivers should be mandatory.
Recommendation #4: Employers should consider diverting
foot traffic away from log loader path ways.
Discussion #4: In this case, the path taken by employees
from the mill to the parking area crosses the log loader path
to the chipper at 90 degrees. Diverting the path taken by employees
would reduce the collision hazard. Even if employees are hard
of hearing, eliminating the potential by re-directing foot traffic
may prevent future injury to employees.
Brhel and KjFr
Precision Sound Level Meter, Type 2232, EC 651 Type 1, Corresponding
Calibrator, Made in Denmark.
OSHA 1910.265 (C) (30) (ii) Vehicle Warning Signals.
OSHA 1910.165 Appendix A - 2. Alarm Signal Alternatives.