A spotter was directing truck loading activities when he was struck from behind & run over by a Front End Loader on the 10th of February 2012 at Timalia Boulder Pit in the Southern Highlands Province.
The incident happened between 12:30 and 1:00 p.m. He was employed by a landowner company contracted to perform work at the Timalia Boulder Pit for the Komo Airfield. He was a member of his local church and actively participated in the church activities. He will be missed by his church members. Since he was the eldest of the family, he controlled and looked after the family. He was also a community leader and made decisions in the village. Because of his leadership, he was a reserve police officer and attended to issues in the community.
It was a great loss to the family. His leadership in the family will not be seen anymore. His wife and eight children will miss him, and this will have a big impact on their lives. Someone who is very close and supportive throughout their lives now will not be seen and felt beside them anymore. It will be a vacuum in their lives especially his children and wife. He will be terribly missed.
He started with the Komo Project on October 5, 2011. He was an enthusiastic worker who took great pride in his work as well as pride in the project. He showed a flair for spotting with many local children mimicking his directions. Hangu was well liked by all the Quarry workers and was a reliable employee. He received many awards/incentives for the work he did and the role model he was.
Accident & Root Cause Analysis
- The Spotter routinely left a pedestrian walkway & entered the plant/equipment traffic area so he could better direct truck loading activities
- The operator of the front end loader had a blind spot which reduced his ability to see out of the right side of his equipment
- The blind spot was caused by the position of a factory fitted load cell computer, cabin post, rearview mirror & operator ergonomics
- Combined, these factors created a 52-degree blind spot within a 90-degree arc
- Spotter & operator were unaware of each others’ tasks
- IP Left Position #1 (Pedestrian Walkway) & Entered Traffic Area – Spotter position was not designated and pedestrian exclusion zones were not in place/enforced
- Front End Loader Blind Spot – Combination of operator ergonomics, location of load cell, position of mirror & the right front corner post of the front end loader’s cabin
- Front End Loader Operator Drove Between Stock Piles – Operator drove an unexpected route which was opposite to the accepted practice (driving counter clockwise around stockpiles) when loading trucks
- Front End Loader Operator Executed An Unscheduled Task – Task was not approved by First Line Supervisor & was unknown to the IP
Recommended Actions (From Company Involved)
- Designate & enforce pedestrian exclusion zones for all personnel for sites where vehicle & machinery are operating
- Ensure competent Supervision (front-line) is present & effective at the worksite
- Assess the need to have spotters & remove all unnecessary positions if it is safe to do so
- Assign clearly marked spotters positions & confine spotter movement to a designated safe zone, monitor compliance & address at-risk behavior
- Clearly identify spotters (specific PPE, color & type, etc.)
- Discuss & publicize route/traffic changes at Tool Box Talks & Pre-Starts
- FLS to assess operator machine interface (ergonomics) to minimize blind spots (blind spots due to equipment configuration/operator height)
- Consider implementing a two way communication model (radios or standardized whistles, flags& vehicle light flashes etc.) to ensure messages between operators & spotters are understood &acknowledged
- Operator: If you don’t see your assigned spotter, do not move
- Spotters: Never turn your back on operating or moving plant/equipment without first getting confirmation from the Operator that it is safe to do so
Lessons for Me and My Family
- No one is immune to accidents, neither the good nor the bad, neither the young nor the old, neither the inexperienced nor the experienced….no one
- It takes only one mistake for a tragedy to occur
- Our families rely on us to work safely and return home to them every day
- Deviating from standard operating procedure is a recipe for disaster; we must always follow established procedures
- There is no justification for unsafe behavior, whether the outcome is fatal or we manage to get away with it
- Risks are inherent in equipment, machinery and the workplace even with the best engineering controls; however if we do the rights things and do things the right way, we can effectively manage them
- The best Safety Management System and most developed procedures are ineffective if we don’t play our role and enforce them as well as follow them.
Berkley Industrial Comp is pleased to share this material with its customers. Please note, however, that nothing in this document should be construed as legal advice or the provision of professional consulting services. This material is for general informational purposes only, and while reasonable care has been utilized in compiling this information, no warranty or representation is made as to accuracy or completeness.