WORKER CONTACTED BY LATHE Type of Incident: Fatality Date of Incident ... · 17-07-2012 · The...
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WORKER CONTACTED BY LATHE Type of Incident: Fatality Date of Incident: July 17, 2012
Transcript of WORKER CONTACTED BY LATHE Type of Incident: Fatality Date of Incident ... · 17-07-2012 · The...
WORKER CONTACTED BY LATHE Type of Incident: Fatality Date of Incident: July 17, 2012
File: F- OHS-026916-36D55
2 Jobs, Skills, Training and Labour, Occupational Health and Safety Date: February 5, 2014
SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred on July 17, 2012.
SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES 2.1 Owner 2.1.1 TISI Canada Inc.
2507 – 87th Ave NW Edmonton, Alberta T6P 1K1
2.2 Employer 2.2.1 TISI Canada Inc.
2507 – 87th Ave NW Edmonton, Alberta T6P 1K1
2.3 Other Employer 2.3.1 Shell Canada Ltd.
P.O. Box 5670 Fort McMurray, AB T9H 4W1
2.4 Workers 2.4.1 Machinist ( )
2.4.2 Administrator ( )
2.4.3 Senior Account Manager ( )
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SECTION 3.0 DESCRIPTIONS OF PRINCIPAL PARTIES
3.1 Employer
3.1.1 TISI Canada Inc. is a Canadian branch to Team Industrial Services. Team Industrial Services is the worldwide company providing services that enable companies to maintain and operate their facilities. Their industrial services includes valve repair, hot tap, field machining, technical bolting, pipe repair, NDE/NDT inspection, emissions control, field heat treating, leak repair, and valve insertion. TISI Canada Inc. had a contract with Shell Canada Ltd. to supply a machinist in the truck shop on the Shell Albian Sands worksite.
3.2 Other Employer
3.2.1 Shell is the operator of Shell Albian Sands, a joint venture oil sands operation. The operations include an open pit mine, ore preparation area, bitumen extraction facility and hydrocarbon mixing facility. Diluted bitumen is transported through a pipeline to Shell’s Scotford Upgrader located in Fort Saskatchewan, Alberta.
3.3 Workers
3.3.1 Machinist ( ) was employed by TISI Canada Inc. to conduct machinist work on a shift rotation on the Shell Canada site as required by Shell Canada Ltd.
3.3.2 Administrator ( ) was employed by TISI Canada Inc. to conduct administrative duties at the regional office at 235 MacAlpine Crescent.
3.3.3 Senior Account Manager ( ) was employed by TISI Canada Inc. to manage the accounts and be the service representative at the regional office at 235 MacAlpine Crescent.
SECTION 4.0 LOCATION OF INCIDENT 4.1 The incident occurred at 235 MacAlpine Crescent at the TISI Canada Inc. town shop
in Gregoire Industrial Park in Fort McMurray. (Refer to Attachment A – Map).
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SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS
5.1 Equipment and Material
5.1.1 Modern Lathe
The Modern Lathe is a large, heavy-duty piece of equipment consisting of a number of components including; the headstock, the bed, the feed and leadscrews, a carriage, a cross slide, a compound rest, a tool post, and a tailstock. It can used by a machinist to either machine, cut or notch various pieces of metal such as steel, brass, iron and so forth (Refer to Attachment C – Photograph 1).
5.2 Observations 5.2.1 When the Officer arrived on site, a light vehicle was parked outside the back of the
shop and the garage door was half way open. The incident scene was secured with caution tape around the surrounding area of the lathe (Refer to Attachment C – Photograph 9).
5.2.2 The lathe control panel had the following configuration: - the speed change lever was set to Y;- the high/low lever was set to H;- the main speed select lever was set to 525 RPM’s;- the forward/reverse lever was set to the left in reverse;- the start spindle control knob was set to neutral;- the thread level select lever was set to 1(Refer to Attachment C – Photograph 1).
5.2.3 The spacer that was being fabricated at the time of the incident was locked in the spindle with one side of the spindle completed and the second side was being polished in preparation for threading. There were portions of coveralls and a t-shirt wrapped around the area of operation and a glove and emery tape wrapped around the polished end of the spacer. A pair of safety glasses was found inside the lathe underneath the spacer and several metal shavings found under the lathe. (Refer to Attachment C – Photograph 3).
5.2.4 On the shop floor in front of the lathe there was another portion of a t-shirt, a ball cap and a fully completed spacer (Refer to Attachment C – Photograph 2).
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SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT
6.1 On July 15, 2012 Shell Truck Shop Team Lead ( ) and Machinist ( ) discussed the specifications for a spacer needed for changing out struts on haul trucks. Machinist ( ) informed Truck Shop Team Lead (
) that the lathe located in the TISI Canada Inc. town shop in Fort McMurray would be the best piece of equipment to fabricate the spacer. At approximately
) left the Shell site. around 12:00 PM Machinist (
6.2 On July 16, 2012, Machinist ( ) started work on the spacer at the TISI Canada Inc. town shop. Machinist ( ) worked on the spacers throughout
the day and left the town shop at approximately 3:30 PM.
6.3 At approximately 7:00 PM on July 16, 2012, the Acting Shop Supervisor () conducted a scan of the shop prior to leaving the worksite. No one was in
the shop so Acting Shop Supervisor ( ) locked the door and left.
6.4 An undetermined time after the departure of Acting Shop Supervisor () from the shop, Machinist ( ) returned to the shop to finish the
work he needed to complete on the spacers. While polishing the stock of a spacer with emery tape, the Machinist’s ( ) glove and coveralls become entangled in the rotating spacer. Machinist ( ) suffered an injury behind his left ear.
6.5 On July 17, 2012 at approximately 7:45 AM, WinRoc Laborer ( ) and WinRoc Laborer ( ) noticed the Machinist ( outdoors on the asphalt behind the shop. They approached the Machinist ( ) and could see that he was injured. Both Winroc workers walked into the Team Industrial shop and informed Administrator ( ) and Senior Account Manager (
) that there was an injured worker behind the shop. A worker from a neighboring business called 911.
) and Senior Account Manager (6.6 Administrator ) ran out back to find Machinist ( ) located beside the passenger side rear door of the company truck (Refer to Attachment C – Photograph 10). The Machinist ( ) was lying on the ground with parts of his coveralls torn.
6.7 Administrator ( ) and Senior Account Manager ( ) talked to Machinist ( ) but he was unresponsive. They stayed with the worker until the ambulance came.
6.8 The paramedics arrived in the ambulance and took Machinist ( ) to the hospital in Fort McMurray. Machinist ( ) was later transported to a Hospital in Edmonton. On July 18 Machinist ( ) died in the hospital.
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SECTION 7.0 FOLLOW-UP/ ACTION TAKEN
7.1 Industry 7.1.1 TISI Canada Inc. complied with demands written, and supplied Occupational Health
and Safety with required information. TISI Canada Inc. had developed a procedure for the operation of a lathe which included it to be locked out while not in use and would require the supervisor to unlock it when it requires use. TISI Canada Inc. also developed a pre-use check sheet for the lathe and a new competency evaluation form for their workers.
7.1.2 Shell Canada Ltd. complied with the demands written, and supplied Occupational Health and Safety with the required information.
7.2 Additional Measures 7.2.1 No additional measures were required.
SECTION 8.0 SIGNATURES
____________________________ _____________________ Original Signed, Investigator Date
____________________________ _____________________ Original Signed, Investigator Date
____________________________ _____________________ Original Signed, Manager Date
____________________________ _____________________ Original Signed, Director Date
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ATTACHMENTS:
Map Diagrams or Sketch
SECTION 9.0
Attachment A Attachment B Attachment C Photographs
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Attachment “A” – Map
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Incident Location
The incident occurred at 235 MacAlpine Crescent at the TISI Canada Inc. town shop in Gregoire Industrial Park, Fort McMurray.
Incident Location
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Attachment “B” – Scene Diagram
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The incident scene diagram was developed by Occupational Health and Safety. The diagram demonstrates the layout of the equipment at the time of the incident. Note the yellow arrow identifying the location of the worker where he was found on the morning of July 17th, 2012.
1. Office area2. Inside truck3. Garage door4. Outside truck5. Worker location6. Unfinished spacer7. Lathe8. Finished spacer
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Attachment “C” – Photographs
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(This photograph was taken by Occupational Health and Safety.)
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Photograph #1
This is a photograph displaying the lathe and the incident scene when the investigators arrived.
1. Unfinished spacer2. Where worker was standing at the time of the incident3. Finished spacer
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(This photograph was taken by Occupational Health and Safety.)
Photograph #2
This is a photograph displaying the finished spacer. The threaded portion of the unfinished spacer is what the worker was polishing just before the incident occurred.
1. Threaded portion of finished spacer
1
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(This photograph was taken by Occupational Health and Safety.)
Photograph #3
This is a photograph displaying the Lathe when it was found at the time of the incident.
1. Coveralls, t-shirt and gloves tangled in the spacer
1
File: F- OHS-026916-36D55
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(This photograph was taken by Occupational Health and Safety.)
Photograph #4
This is a photograph displaying the tangled clothing in the spacer and the lathe. Note the worker's coveralls, t-shirt and his left glove that were tangled in the spacer. Also note the worker's left glove was tangled with the emery tape as well.
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(This photograph was taken by Occupational Health and Safety.)
Photograph #5
This is a photograph displaying the final layer of the entanglement around the spacer.
1. Emery tape overlapping itself
1
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(This photograph was taken by Occupational Health and Safety.)
Photograph #6
This is a photograph displaying the final layer of the emery tape around the spacer.
1. Emery tape overlaps itself2. Where the worker's right hand was grasping the emery tape3. Left hand thumb print on emery tape
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(This photograph was taken by Occupational Health and Safety.)
Photograph #7
This is a photograph displaying the left thumb imprint on the emery tape.
1. Left thumb print on emery tape
1
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(This photograph was taken by Occupational Health and Safety.)
Photograph #8
This is a photograph displaying the emery tape folding in upon itself.
1. Indent of folded emery tape
1
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(This photograph was taken by Occupational Health and Safety.)
Photograph #9
This is a photograph displaying the back of the shop.
1. Area where the worker was standing at the time of the incident
1
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(This photograph was taken by Occupational Health and Safety.) Photograph #10
This is a photograph displaying the passenger side of the company truck. This is the vehicle
used to travel back and forth from the Shell Site. Note where the worker was found lying perpendicular to the truck with his head under the passenger side door.
1. Area where the worker was found the next morning
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