FACE Report: Manufacturing laborer falls from elevated pallet

Case report: #24KY022
Issued by: Kentucky State Fatality Assessment and Control Evaluation Program
Date of report: July 31, 2024

A 62-year-old man was employed by a company that specializes in the manufacture of additives to enhance the performance and durability of concrete. On the day of the incident, the laborer was tasked with the production of a viscosity modifier additive, a task he performed several times monthly. The task required him to empty the contents of a 132-pound drum into a commercial-grade mixer that sat about 5 feet from the concrete surface below. To access the mixer, the approved procedure in place at the time required employees to place the drum onto a wooden pallet. Once on the pallet, the drum and pallet were lifted via forklift to the edge of the mixer. An 8-foot stepladder was then placed beside the elevated pallet, and employees climbed the ladder to access the drum. From the ladder, the drum could be tilted forward to empty its contents into the mixer. The process required employees to improperly use ladders. In addition, investigators discovered post-incident that employees frequently stood on top of the pallet while emptying the drum. While attempting to mix the contents of the drum into the mixer while standing on the pallet, the laborer fell 4.5 feet, striking the concrete surface below. Another employee saw the impact of the victim striking the surface below. Emergency responders arrived and transported the victim to a university medical center, where he died the next day. Cause of death was listed as subdural hematoma with midline shift sustained in the fall.

To help prevent similar occurrences, employers should consider:

• Using a drum-handling device in lieu of working at height.
• Modifying procedures to prioritize the use of two employees when possible.
• Implementing an auditing process to ensure compliance with company procedures.
• Requiring hard hats equipped with chin straps when working at height.