FACEValue: Worker killed after being pulled into mortar mixer

NIOSH’s Fatality Assessment and Control Evaluation Reports
#2003-13
Date of incident: May 15, 2003

An 18-year-old laborer was killed after he became entangled in a portable mortar mixer at a residential construction site. The victim was employed by a bricklaying company. Company owners provided a hands-on demonstration and training to all employees, including the victim, although no documentation was made. The construction site was equipped with a portable mortar mixer with a gasoline-powered engine. The mixer was equipped with a guard and an automatic lift that allowed 8 inches of clearance for mortar to be poured through. However, the paddles of the mixer could be engaged regardless of the position of the drum or the guard. At the end of the shift, the victim began cleaning out the mixer with a garden hose. A short time later, a painter working nearby heard the victim yell for help and ran to the machine to find the victim’s arm stuck and his body being pulled in by the rotating mixer paddles. The painter was unable to shut off the machine and yelled for assistance. After hearing the noise, another bricklayer arrived to shut down the machine. By this time, only the victim’s leg was protruding from the mixer. A neighbor called 911 and emergency services arrived within minutes. The victim was declared dead at the scene.

To prevent future occurrences:

• Employers should develop, implement and enforce a written safety program that includes task-specific hazard identification and abatement. Employers should evaluate all tasks performed by workers and design a written safety program that addresses these tasks specifically. In this case, a written safety program could have informed the victim of hazards associated with cleaning the mixer. A clear lockout/tagout program should have been enforced.
• Employers should train workers in hazard recognition and control, and should conduct and document regular safety meetings. Workers should be trained not only to recognize hazards, but also to eliminate them. Although cleaning operations were demonstrated with the guard in place on the mixer, there is no evidence the victim received any training on the hazards associated with cleaning the mixer without the guard in place.
• Employers should ensure equipment is operated according to manufacturer’s recommendations. The manual for the mixer involved in this incident clearly stated that users should not stick their hands inside the mixer while it is in operation, and the guard should be left in place whenever the mixer is operating.