FACEValue: Laborer killed while attempting to clean a concrete mixer

NIOSH’s Fatality Assessment and Control Evaluation Reports
#95-12
Date of incident: May 15, 1995

A 25-year-old laborer at a concrete pipe manufacturing facility died from injuries he sustained while trying to clean a ribbon-type concrete mixer. The victim was employed for 11 months at the plant, which manufactured concrete sewer pipes. Although the employer had handwritten safety procedures that included a lockout/tagout process, the employer provided no formal training and instead offered on-the-job orientation. The victim was a Mexican immigrant who read and understood very little English. The standard procedure for cleaning the mixer was to shut off power at the breaker box about 35 feet from the mixer, push the toggle switch on the machine to ensure power was off, and then enter the mixer to scrape the inside and shovel the concrete debris out of the chute. The mixer was to be cleaned out daily by both a laborer and mixer operator. Prior to the incident, the mixer operator turned off the power at the main breaker and then went to make a phone call before verifying power was off by pushing the toggle switch. During his absence, the victim, unaware the operator had already shut off power at the breaker, went to the box and inadvertently turned the power back on. He then entered the mixer without checking power at the toggle switch. When the operator returned, he turned on the toggle switch, intending to verify the machine was de-energized, and heard the victim inside scream. The operator immediately shut the mixer off at the main breaker. EMS arrived and transported the victim to a local trauma center, where he died four hours later.

To prevent future occurrences:

• Employers should conduct a safety hazard analysis of all work locations in all plants and implement corrective action where necessary. Each work location at every plant should be evaluated for potential safety hazards. In this case, the breaker box was located about 35 feet from the mixer room and was not equipped with a safety lockout.
• Employers should develop, implement and enforce a written safety program that includes task-specific training and lockout/tagout procedures. Although the employer in this incident had a handwritten safety program, the safety program should have been formalized throughout the entire company. Written policies should include a description of safe work procedures for all tasks to be conducted. It should cover safe use of machinery and required personal protective equipment. If workers do not speak English, safety procedures should be delivered both verbally and in writing in a language that is understood by the worker.