Fatality Assessment and Control Evaluation (FACE) Program

Fourteen-Year-Old Rental Equipment Worker Dies from Asphyxiation After Becoming Entangled in an Electric Chain Hoist - Colorado

Summary

On July 21, 2001, a 14-year-old youth (the victim) working at a rental equipment company was fatally injured after becoming entangled in an electric chain hoist. The youth was employed to assist customers with loading and unloading rental equipment from customer vehicles and to prepare rental equipment for use by the next customer. After using the electric hoist to remove a vibratory plate tamper from a customer's truck, he was seen operating the chain hoist without a load. Several minutes later, when he had not returned to the office, his coworkers found him suspended by the chain around his neck. He was removed from the chain by his coworkers, cardiopulmonary resuscitation (CPR) was initiated, and emergency medical services were called. He was transported by ambulance to the hospital in critical condition and died 6 days later.

NIOSH investigators concluded that, to help prevent similar incidents, employers should

• ensure that adequate adult supervision is provided for youth workers. Training for all adult workers should emphasize their responsibility to monitor, and intervene when necessary, if unsafe activities are being performed by youth coworkers
  
  
• implement training programs targeted at youth workers which emphasize the link between unsafe behavior and the potential for injury
  
  
• review the tasks to which youths are assigned and ensure that the assigned tasks are as inherently safe as possible, given the relative inexperience of youth workers
  
  
• place return chain containers on all chain hoists to decrease the risk of becoming entangled in the return chain

Additionally, the Department of Labor should

• consider amending child labor regulations to remove the exemption for less than one ton capacity when using an electric or air-operated hoist

Introduction

On July 21, 2001, a 14-year-old rental equipment worker (the victim) died as a result of asphyxiation after becoming entangled in the chain of an electrically powered chain hoist. On August 3, 2001, the National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR), was notified of the incident by the US Department of Labor, Wage and Hour Division. On September 12, 2001, a DSR occupational safety and health team met with representatives of the U.S. Department of Labor, Wage and Hour Division, and the Occupational Safety and Health Administration (OSHA). During these visits, information collected during the Wage and Hour Division and OSHA investigations were reviewed. On September 13, 2001, the DSR occupational safety and health team met with representatives of the local Police Department, the County Coroner's Office, and the County Office of Vital Statistics and spoke with the employer's legal counsel. A formal visit to the site of the incident could not be arranged due to the absence of the business owner. Photographs were obtained from the Wage and Hour Division and OSHA investigations.

The equipment rental business had been in operation for 43 years. The location where the incident occurred is one of two operated by the company. The business employed approximately 27 workers, including 9 youths. At the time of the incident, three workers were at the business location, the victim and two adults. The business had no formal or written workplace safety policies, although there were some basic written safety procedures. The victim had been trained to operate the chain hoist by his father (also an employee). All training was provided on the job. This was the first fatality experienced by the business.

Investigation

At the equipment rental business, customers often use their pickup trucks to transport equipment from the business to the use location. To facilitate the loading and unloading of this equipment, the business installed a small swing-arm crane with an electric hoist attached outside the building. When a piece of heavy equipment was rented, the rental equipment employees would locate the equipment under the hoist then use the hoist to raise the equipment high enough for the customer's truck bed to pass beneath. The equipment was then lowered onto the truck bed and disconnected from the hoist. When the equipment was returned by the customer, the hoist was used to raise the equipment off the bed of the truck. The truck would be driven away and the equipment lowered to the ground.

On the day of the incident, the victim started work between 7:30 and 8 a.m. The victim and two coworkers loaded and unloaded rented equipment from customer-owned vehicles and serviced returned equipment. At approximately 3 p.m., the victim and a coworker used the electric hoist to remove a vibrating plate tamper, weighing between 150 and 200 pounds, from the customer's pickup truck. After the tamper had been unloaded, one coworker went to the restroom and the other went across the lot to the company office. During OSHA interviews, coworkers stated that the victim had on previous occasions been observed placing the hoist hook in a belt loop of his pants and raising himself off the ground. Several minutes later, the coworker in the office noticed that the tamper had not yet been taken into the service area and went to investigate. The coworker discovered the victim raised above the ground with the chain around his neck, and he was not breathing. The coworkers removed him from the chain, initiated cardiopulmonary resuscitation (CPR), and called Emergency Medical Services (EMS) from the office phone. The victim was treated by the fire department quick-response unit and EMS personnel at the scene and transported by ambulance to the hospital in critical condition. The victim died 6 days after the incident.

The hoist involved had a rated capacity of a half ton (500 kg) and a chain speed of 16 feet per minute. The electric motor size was ½ horsepower. The hoist did not have a supply chain container, leaving a loop of free chain hanging in addition to the hoist chain. The ASME/ANSI B30.16 ¹ safety label was in place on the control cable just above the control paddle and was clearly legible. This label includes the warning (#5), "DO NOT Lift people or lift loads over people." After the incident, OSHA had the hoist inspected, and the only flaw noted was the absence of a spring-loaded latch on the hook. The controls, motor, and chain were found to be in normal working order.

Cause of Death

The county coroner determined the cause of death to be asphyxia by hanging.

Recommendations/Discussion

Recommendation #1: Employers should ensure that adequate adult supervision is provided for youth workers. Training for all adult workers should emphasize their responsibility to monitor, and intervene when necessary, if unsafe activities are being performed by youth coworkers.

Discussion: It was stated by coworkers that the victim had previously been observed raising and lowering himself with the hoist. From the OSHA interview it is clear that at least one of the adult coworkers was aware of unsafe activity, yet there was no reported effort on the part of the adults working at the time to stop this activity by the victim. There is no evidence that any training specific to the supervision of youth workers was provided to the adult employees.

Recommendation #2: Employers should implement training programs targeted at youth workers which emphasize the link between unsafe behavior and the potential for injury.

Discussion: The victim was reported to have engaged in a clearly unsafe act, raising and lowering himself with the electric hoist. This clearly is not the intended use of the hoist and is specifically warned against by the label on the hoist control cable. Additional risks of a hoist include being struck by the hook or the load, being caught between the load and another object, and becoming caught on the load as it is raised or lowered. There is no evidence that the victim had ever received training on the risks of unsafe actions.

Recommendation #3: Employers should place return chain containers on all chain hoists to decrease the risk of becoming entangled in the return chain.

Discussion: Chain hoists are typically constructed using a single length of chain. Exiting the hoist assembly is the single chain that supports the load plus a loop of return chain that grows in length when the load is lifted and shrinks when the load is lowered. Were a worker to become entangled in the return chain, it would be very difficult for the worker to free himself (he would need to push the up button to be let down). Return chain containers are typically either metal or canvas boxes or buckets which receive and pay out chain as is it needed for the lifting operation, thus eliminating the return chain loop. Return chain containers remove the hazard of becoming entangled in the return chain and should be used on all powered hoists.

Recommendation #4: Employers should review the tasks to which youth are assigned and ensure that the assigned tasks are as inherently safe as possible, given the relative inexperience of youth workers.

Discussion: The employer should look at each task assigned to a youth worker and remove as many of the identifiable hazards as possible. In this case, the youth was working with an electric chain hoist. Replacing the powered hoist with a manual chain hoist would decrease the chain speed and increase the ability to control the load, providing additional safety for the worker. A manual chain hoist, where the operator must pull on a chain to raise and lower the load, will move the hauling chain with a much slower velocity. This would make it much more difficult to inadvertently become caught in the chain, and even if the youth were to become entangled in the chain while operating the hoist, the motion of the hoist would stop as soon as he/she stopped pulling on the chain. The use of a manual (nonpowered) hoist by youth workers allows the worker to perform tasks requiring the use of a hoist with less risk of injury. This type of additional safety review and accommodation should be considered a cost of using youth workers. The business temporarily replaced the electric hoist with a manual one while the electric hoist was being inspected without any inhibition of the business's ability to function.

Recommendation #5: The US Department of Labor (DOL) should consider amending child labor regulations to remove the exemption for less than one ton capacity when using an electric or air-operated hoist.³

Discussion: Youth workers come to an employer with minimal experience in the workplace. They do not have the experience to evaluate the safety of the tasks they are being asked to complete. To protect youth workers, the child labor laws give the DOL the authority to issue special regulations for workplaces where youths are employed. The Hazardous Orders are promulgated by DOL to identify and list recognized dangerous tasks so that youths under the age of 18 can be protected from engaging in these occupations. The current Hazardous Order #7 (29 CFR 570.58) states that "the following occupations involving operation of power-driven hoisting apparatus are prohibited: 1. Work of operating an elevator, crane, hoist, or highlift truck (including a forklift) except operating an unattended automatic elevator or an electric or air-operated hoist not exceeding one ton capacity." The hazards of a powered hoist are twofold: first is the risk of the load either falling or being mishandled, and the second is the risk of being caught in/by the moving chain. Both of these hazards are present regardless of the capacity of the hoist, and a one ton load could certainly cause considerable injury to the worker were it to be dropped or handled improperly. These risks are not changed by the weight of the load, and precluding youths from operating all powered hoists would provide more protection.

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References

1. ASME/ANSI[1998]. Overhead hoists (underhung). New York:American Society of Mechanical Engineers/American National Standards Institute, B30.16.
   
   
2. DOL [March, 2001]. Child labor requirements in nonagricultural occupations under the Fair Labor Standards Act. Washington, D.C.: U.S. Department of Labor, Employment Standards Administration, Wage and Hour Division, WH-1330.
   
   
3. NIOSH [2001]. National Institute for Occupational Safety and Health (NIOSH) Recommendations to the U.S. Department of Labor for Changes to the Hazardous Orders - Morgantown, WV: Division of Safety Research.

Investigator Information

This investigation was conducted by Carl Werntz, DO, Occupational Medicine Resident at West Virginia University assigned to NIOSH, Division of Safety Research, Surveillance and Field Investigations Branch, Special Studies Section; Virgil Casini, Safety and Occupational Health Specialist, NIOSH, Division of Safety Research, Surveillance and Field Investigations Branch, Fatality Assessment and Control Evaluation Team; and Anne Mardis, MD, MPH, Epidemiologist, NIOSH, Division of Safety Research, Surveillance and Field Investigations Branch, Special Studies Section.

FATALITY ASSESSMENT AND CONTROL EVALUATION (FACE) PROJECT

The National Institute for Occupational Safety and Health (NIOSH), Division of Safety Research (DSR), performs Fatality Assessment and Control Evaluation (FACE) investigations when notified by participating states (North Carolina, Pennsylvania, South Carolina, Tennessee, and Virginia); by the Wage and Hour Division, Department of Labor; or when a request for technical assistance is received from NIOSH-funded state-level FACE programs in Alaska, California, Iowa, Kentucky, Massachusetts, Minnesota, Missouri, Nebraska, New Jersey, Ohio, Oklahoma, Texas, Washington, West Virginia, and Wisconsin. The goal of these evaluations is to prevent fatal work injuries in the future by studying the work environment, the worker, the task the worker was performing, the tools the worker was using, the energy exchange resulting in fatal injury, and the role of management in controlling how these factors interact. The FACE program does not seek to determine fault or place blame on companies or individual workers. For further information visit the FACE Web site at www.cdc.gov/niosh/face/ or call toll free 1-800-35-NIOSH.