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INCIDENT |
SPOTTER STRUCK & KILLED BY FRONT END LOADER |
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DATE |
10 February 2012 |
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DESCRIPTION |
A spotter was directing truck loading activities when he was struck from behind & run over by a Front End Loader |
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KEY POINTS
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•The Spotter routinely left a pedestrian walkway & entered the plant/equipment traffic area so he could better direct truck loading activities
•The operator of the front end loader had a blind spot which reduced his ability to see out of the right side of his equipment
•The blind spot was caused by the position of a factory fitted load cell computer, cabin post, rear view mirror & operator ergonomics.
•Combined, these factors created a 52o blind spot within a 90o arc
•Spotter & operator were unaware of each others’ tasks
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RECOMMENDATIONS
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•Designate & enforce pedestrian exclusion zones for all personnel for sites where vehicle & machinery are operating
•Ensure competent Supervision (FLS) is present & effective at the workface. No Supervision/FLS = No work
•Assess the need to have spotters & remove all unnecessary positions if it is safe to do so
•Assign clearly marked spotters positions & confine spotter movement to a designated safe zone, monitor compliance & address at-risk behavior
•Clearly identify spotters (specific PPE, color & type etc)
•Discuss & publicize route/traffic changes at Tool Box Talks & Pre-Starts
•FLS to assess operator machine interface (ergonomics) to minimize blind spots (blind spots due to equipment configuration/operator height)
•Consider implementing a two way communication model (radios or standardized whistles, flags & vehicle light flashes etc) to ensure messages between operators & spotters are understood & acknowledged
•Operator: If you don’t see your assigned spotter, do not move
•Spotters: Never turn your back on operating or moving plant/equipment without first getting confirmation from the Operator that it is safe to do so
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Incident Root Causes & Schematic
Root Cause (4)
1.IP Left Position #1 (Pedestrian Walkway) & Entered Traffic Area
+Spotter position was not designated and pedestrian exclusion zones were not in place/enforced
2.Front End Loader Blind Spot
+Combination of operator ergonomics, location of load cell, position of mirror & the right front corner post of the front end loader’s cabin
3.Front End Loader Operator Drove Between Stock Piles
+Operator drove an unexpected route which was opposite to the accepted practice (driving counter clockwise around stockpiles) when loading trucks
4.Front End Loader Operator Executed An Unscheduled Task
+Task was not approved by First Line Supervisor & was unknown to the IP
