|Massachusetts Case Report: 92MA013
October 22, 1992
A 30 year old male Massachusetts lumber company/sawmill laborer died
on April 29th, 1992, approximately one month after being struck in the
head during routine maintenance operations. The victim was sweeping sawdust
and waste wood debris from the floor of a sawmill chipper room when he
struck his head on an operating chipper machine shaker table. Suffering
a headache as a result, the victim left work in the middle of the day.
Complaining of headache and nausea, the victim was admitted to the regional
hospital the following day for treatment of a concussion, subsequently
discharged, and cleared to return to work at a later date. Nine days following
his return to work, the victim was again hospitalized and soon died from
a brain aneurysm.
The Massachusetts FACE Investigator concluded that to prevent similar
occurrences in the future, employers should:
- Select and appoint a designated safety person to develop, implement,
and enforce a comprehensive safety program that includes, but is not
limited to, the use of head protection and the dangers associated with
work in the lumber/sawmill industry.
- Contact sawmill equipment manufacturer(s) to design or assist in the
design of equipment safeguarding systems that would prevent employee
exposure to blunt, moving, or revolving machinery parts.
- Restrict use of nonessential, hearing prohibitive personal equipment
when working in areas that are typically known to be significantly hazardous.
- Develop and implement a medical monitoring protocol to ensure that
employees suffering potentially dangerous injuries, especially blows
to the head, seek immediate medical surveillance and determine, if possible,
if all medical recommendations have been followed prior to authorizing
return to work.
On Monday, July 27, 1992, following review of recently submitted OSHA
fatality data, the Massachusetts Department of Public Health Occupational
Fatality Study Coordinator contacted the MA FACE Program Field Investigator
to report a questionable traumatic occupational death occurring on April
29, 1992. The MA FACE Program Field Investigator was soon able to determine
that the fatality, although not of the targeted variety, warranted a FACE
Program related study. On July 28, 1992, the MA FACE Investigator reviewed
the OSHA fatality file on this matter and subsequently spoke with the
The employer was a regional lumber manufacturing facility in business
for 19 years. It employed 15 persons in clerical, sawyer and laborer capacities.
The company did not employ a designated safety person, nor did it have
written comprehensive safety and health policies and/or procedures in
place at the time of the incident.
The victim was a company laborer for 1 year and 11 months whose training
was primarily on the job. Normally, the victim worked in the finished
lumber storage area where he would receive lumber slabs by conveyor and
stack them according to length and width.
The employer's first report of injury, the death certificate, medical
information, and FOI excerpts of the OSHA record were obtained during
the course of the investigation.
On the day of the incident, the sawmill was shut down in anticipation
of performing routine maintenance on the chipper which included the replacement
of bearings and knives. The company President, Vice President, and two
employed sawyers performed all of the chipper related maintenance at approximate
eight month intervals.
The investigation revealed that on Friday, March 27th, following "blowdown"
of excess sawdust by a coworker that had accumulated in the chipper house,
the victim, who normally worked in the storage area stacking fresh cut
lumber, appeared and offered to sweep up the debris. Accepting the victim's
offer to sweep up, the coworker left the area, leaving the victim, who
was wearing a headphone equipped WalkMan type radio clipped to his belt,
to cleanup by himself.
Later in the a.m., the victim, claiming he had misjudged his location
and struck his head on the chipper shaker table while sweeping up, sought
aspirin from coworkers for relief a resultant headache. The shaker table
portion of the chipper is a vibrates, spins and sifts wood chips needing
to be rechipped again.
Approximately 30 minutes following his initial request for aspirin, the
victim, now with more intensified discomfort, again inquired of his coworkers
if they had stronger medication. Experiencing negligible relief, he left
On the following day, March 28th, the victim was admitted to the regional
hospital as the result of persistent headache and vomiting. After two
days of treatment for a diagnosed concussion, he was discharged from the
hospital, advised to remain out of work for two weeks or so, and to follow
up with a neurologist. On Tuesday, April 14th, a coworker spoke with the
victim who claimed he was feeling better, was NOT going to see the neurologist,
and might be back to work on April 20th.
Although the attending physician did not authorize return to work until
April 27th, the victim returned to work on April 20th and worked routinely
without incident through April 27th. Suffering a seizure April 28th, he
was again admitted to a regional medical center for treatment. On April
29th, the victim's wife telephoned the employer at 7:45 a.m. to report
that her husband was near death in the regional hospital with a brain
aneurysm. He died approximately two hours later on the same day.
Cause of Death
The medical examiner listed the cause of death as (Yet To Be Determined).
Recommendation #1: Employers should select and appoint a designated
safety person to develop, implement, and enforce a comprehensive safety
program that includes, but is not limited to, the use of head protection
and the dangers associated with work in the lumber/sawmill industry.
Discussion: Although it cannot be definitively proven that the victim's
jobsite related blow to the head caused the resultant brain aneurysm or
that head protection may have prevented it, the employer lacked effective
development and enforcement of comprehensive safety and health provisions,
including but not limited to, a head protection program in an industry
typically noted as highly hazardous. The appointment of a designated safety
person to develop, implement, and enforce a comprehensive safety program
that included head protection requirements in such high hazard industry
remains a fundamental requirement that should be strictly adhered to.
(See OSHA Standard 29 CFR 1910.132 (a))
Recommendation #2: Employers should contact sawmill equipment manufacturer's
to design or assist in the design of equipment safeguarding systems that
would prevent employee exposure to blunt, moving, or revolving machinery
Discussion: While there are many industrial related machinery safeguarding
requirements in existence, the sawmill chipper shaker table is not among
those pieces of equipment covered by current standards. In the absence
of such requirements, employers should attempt to identify work area hazards
not covered by current standards and take appropriate measures to reduce
or eliminate potential employee exposures. Historically, many employers
have successfully petitioned equipment manufacturer's to design, or assist
in the design, of machinery related safeguarding systems that while not
required, have significantly aided them in the reduction or elimination
of work related mishaps. NOTE: In the absence of manufacturer installed
safeguarding systems, the employer is strongly encouraged to work very
closely with the equipment manufacturer, and a legal representative, in
the development, design, and installation of specific safeguarding systems.
Compromising and/or altering the intended manufactured use of any equipment
by failing to include the manufacturer in the development, design, and
installation of safeguarding systems could result in potentially serious
Recommendation #3: Employer's should restrict use of non essential, hearing
prohibitive personal equipment when working in areas that are typically
known to be significantly hazardous.
Discussion: The incident investigation revealed that the victim was wearing
a headphone equipped WalkMan type radio clipped to his belt when he was
struck by the chipper machine shaker table. It remains extremely vital,
especially in high hazard areas, that employee's be fully aware of their
surroundings. Use of a nonessential, audio inhibiting device in the workplace
seriously impaired the victim's ability to comprehend that he was dangerously
close to the operational chipper machine shaker table. Although this death
may never be directly linked to the unfortunate sequence of events that
preceded it, the victim may not have been struck by the shaker table had
he been fully aware that it was operational while sweeping around it.
Any and all equipment used in the workplace should be actively restricted
to that which is required and necessary to effectively and safely achieve
the desired result.
Recommendation #4: Employers should develop and implement a medical monitoring
protocol to ensure that employees suffering potentially dangerous injuries,
especially blows to the head, seek immediate medical surveillance and
determine, if possible, if all medical recommendations have been followed
prior to authorizing return to work.
Discussion: Although not lawfully required, employer's should consider
the development and implementation of an internal medical incident protocol
that not only demands ALL work related incidents to be immediately reported,
but that assesses the degree of potential employee harm and acts on that
potential. While it is typical for employee's to momentarily rest and
return to work following a strain, sprain, etc., we have seen the results
of a delay in seeking prompt medical attention. Given the likelihood that
any given employee will suffer more acute or chronic medical symptoms
hours, days, or weeks later, it is often imperative that medical intervention
be administered as soon as possible. The possibility of worsening the
present condition, by returning to work unchecked, also remains ever present.
Relative to this incident, the potential harm suffered by the victim
was not considered, assessed, or evaluated. Consequently, no requirement
or encouragement was given by anyone that medical intervention be sought
until persistent headache and subsequent nausea set in the following day.
Secondly, although the attending physician did not authorize return to
work until April 27th, the employer authorized the victim to return to
work one week earlier, on April 20th. There is generally a reason that
physicians require the injured to remain out of work for a specified period
Lastly, when the victim began to feel better, he chose not see a neurologist
against the advice of his attending physician. Had the employer known
of this, he may have refused the victim to return to work until ALL recommended
medical surveillance and treatment had been administered. The issue of
patient/physician confidentiality may obviously hinder an employer's efforts
to do this, however, a letter from the attending physician stating that
the injured is sufficiently rehabilitated to return to work may accomplish
the same goal.
In closing, none of these matters may have had a
bearing on the ultimate end result. However, they show the need for an
internal medical assessment and surveillance protocol to ensure that victim's
of work related incidents obtain timely care and that they do not return
until deemed medically fit.
- Office of the Federal Register: Code of Federal Regulations, Labor
29, July 01, 1991: Part: 1910.132 (a)
- U.S. Department of Labor, Occupational Safety and Health Administration
(Springfield, MA) COSHO Investigative Summary
To contact Massachusetts
State FACE program personnel regarding State-based FACE reports, please
use information listed on the Contact Sheet on the NIOSH FACE web site
Please contact In-house
FACE program personnel regarding In-house FACE reports and to gain
assistance when State-FACE program personnel cannot be reached.