FACE Report: Sawmill loader operator crushed performing maintenance on front-end loader

Case report: #22MI010
Issued by: Michigan State Fatality Assessment and Control Evaluation Program
Date of report: Sept. 8, 2023

A 61-year-old loader operator was killed while attempting to repair a hydraulic line on a front-end loader used to move logs. Repairs to hydraulic lines were a semiregular maintenance activity, occurring every three months or so, and took about 15 minutes to complete. The company had a written lockout/tagout program, but the program did not contain specific procedures for the front-end loader maintenance. At the time of the incident, the loader operator was working with another loader operator. The front-end loader, which was equipped with a log clam, was brought into the maintenance shop area. The boom was raised for access to the hydraulic line. The elevated boom was not blocked up or secured. Several 4-by-6-inch hard wood blocks were available but were not used. The assisting loader operator had to step away and radioed a maintenance worker to take over assisting with the repair. When the maintenance worker arrived at the scene, he found the victim crushed between the boom and the frame. Emergency responders arrived, freed the operator and pronounced him dead. Investigators concluded that the loader operator had loosened the wrong hydraulic line, causing the boom to lower under the load.

To help prevent similar occurrences, employers should:

• Develop, implement and enforce lockout/tagout procedures for maintenance tasks, including the use of cylinder locks or adequate blocking when the boom is required to be in the raised position during servicing and/or maintenance. Pay special attention to all sources of potential energy and ensure all tasks involving the potential release of hazardous energy are covered.
• Conduct periodic inspections of authorized employees and review energy control procedures.
• Develop, implement and enforce a safety and health program that addresses hazard recognition and avoidance of unsafe conditions.
• Ensure employees do not perform potentially hazardous tasks alone.