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Fatality Alert: Confined Spaces Accident Type: Confined space Type of Operations: Unloading rail car Competent Safety Monitor on Site: No Was the Worksite Inspected Regularly: No Training and Education Provided: No Employee Job Title: General Labor Length of Employment: 4 months Experience at this Type of Work: 15-20 times previously Time on Task: 45 min Environmental /Geographic Conditions: Confined Space |
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Brief Description of Accident:
The deceased was filling in for another employee and was unloading a rail car of material, which has a consistency much like flour. As this material offloads, it has a tendency to stick to the sides of the cars. The employee was required to be stationed on top of the car using a long air nozzle to break the material loose and move it toward the vibrating vacuum intake at the bottom of the car. The employee was supposed to wait until most of the material was offloaded before entering the railcar to remove the remaining material from the lower sides and floor of the car.
The employee was working alone so there were no witnesses. The deceased was found, engulfed in the rail car which was almost full. It was assumed that as the material was removed from the bottom, a “crust” formed on the top of the material and created an air pocket void beneath. So, when the deceased entered the car and stepped on the “crust”, he fell through, and was engulfed by the material.
No written Confined Space program was in place for this process. Employees had not received formal training. Although employees were verbally warned not to enter the rail car until it was almost empty, this employee had been known to enter the rail car when it was still full. No formal reprimand had ever been given to him.
Accident Prevention Recommendations:
- Implement a formal Confined Space program meeting all applicable requirements of ”OSHA standard CFR 1910.146 – Permit-required Confined Spaces”
- Conduct formal training for new employees
- Perform routine safety training
- Carry out site inspections to insure safety rules are being followed
- Consistently enforce safety rules
- Conduct training for employees working on unfamiliar or new processes/equipment
- Hold supervisors accountable for their subordinates’ safety performance
