Fatality Assessment and Control Evaluation (FACE) Program
Worker Killed In A Fall In A Bakery Fermentation Tank
On January 10, 2005, a 34-year-old male Hispanic worker was killed when he fell in a seven-feet-deep fermentation tank at a wholesale bakery. The worker was cleaning the lid and outer portion of the top of the tank with a cleaning pad when the pad apparently fell to the bottom of the tank. It is unknown what specifically caused the fatal incident. The worker may have reached too far into the tank and fell to the bottom, or he may have climbed into the tank to retrieve the pad and fell as he descended or as he attempted to climb out. The worker was found inside the tank when he failed to appear for the change-of-shift report.
NJ FACE investigators recommend following these safety guidelines to prevent similar incidents:
On January 12, 2005, NJ FACE staff learned of the death of a 34-year-old Hispanic man who had received fatal injuries from a fall in a tank at a wholesale bakery. Information about the incident had been announced by the print and radio media. That day, a FACE investigator contacted the OSHA compliance officer and arranged to conduct a concurrent investigation, which took place on January 25, 2005. During the visit, FACE investigators viewed and photographed the site of the fatal injury and interviewed company officials, but were not present during employee interviews. Additional information was obtained from the police report, the county prosecutor's office, the medical examiner's report, and the OSHA investigation file.
The victim’s employer was a wholesale bakery with facilities in several countries. The facility in which the incident occurred was three years old, and the company employed approximately 250 workers at the site. The non-unionized company operated 24 hours a day, seven days a week. Most of the production employees were Hispanic. Supervisors spoke English and Spanish. According to the company manager, employees could work and be promoted without being able to speak English. Posted signs were printed in English and Spanish and training was provided in English and Spanish.
The victim’s job title was Senior Operator and he worked in the ingredient preparation area. An immigrant from Guatemala, he reportedly spoke Spanish and English. He had been a full-time employee at the bakery for 15 months and had no prior experience in the industry. His surviving wife and children lived in Guatemala. The company also employed two of his siblings.
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The incident occurred at a large wholesale bakery located in an industrial park in a suburban area of New Jersey. The fatal injury occurred on an elevated platform, where 14 stainless steel dough fermentation tanks of various sizes were located. All equipment was new when installed in the facility. The tank involved in the fatal injury was one of four of the same size and design, all operated by computer control. It had a capacity of 1,750 gallons, with a normal load of approximately 500 gallons of product. The tank was 76 inches in diameter with an 88-inch-deep straight wall, a domed top, and a bottom with a slope of approximately 15 degrees. The access opening on the top of the tank was 19 inches in diameter, and was fitted with a hinged hatch. The height from the platform to the tank opening was approximately 36 inches. The only entrance or exit from the tank was the access opening at the top; there was no ladder, door, or hatch at the bottom.
The interior of the tank contained two stationary vertical rods at the walls of the tank with attached horizontal blades, each of which was fixed at an angle of approximately 30 degrees. In the center of the tank was an agitation device with attached horizontal blades that rotated at 8 revolutions per minute to prevent settling of the contents of the tank.
A fixed spray nozzle located near the top of the tank sprayed water to clean the tank after it had been emptied. Once each week, workers used a cleaning pad to wipe excess product off of the hatch and its rubber seal that was not removed by the regular spray cleaning process. Each fermentation tank was a confined space, and maintenance of the interior of the tank was performed exclusively by the manufacturer's representative using confined space entry procedures. According to the employer, workers were not permitted to enter the tanks.
In the event of a cleaning pad dropping into a tank, it could be retrieved by using a 10-foot-long aluminum pole with a wire hook attached, fabricated by the company.
If that was not successful, a supervisor could arrange to have the 6-inch drain at the bottom of the tank opened and the item retrieved. The pattern of tank use could also be altered so that a tank with the cleaning pad at the bottom could be bypassed and another tank used for production.
The fatal injury occurred on Monday, January 10, 2005, at an undetermined time during his 11 a.m. to 7 p.m. shift. He apparently used a cleaning pad to wipe residue from the inside of the tank hatch and its rubber seal. It was customary for workers to discuss operations when turning over work to the next shift, and when he failed to meet his replacement, he was paged. When he still did not respond, workers searched for him. The day-shift worker who was conducting routine inspections of all of the tanks found the victim at the bottom of the fermentation tank. Also found at the bottom, in approximately one foot of product fluid, was the cleaning pad. The worker summoned his supervisor, who called 911. The police department received the call at 7:17 p.m. Local emergency responders tested the tank for oxygen deficiency, and found it to be within acceptable limits. No information is available on exact measurements. Their confined space rescue team removed the victim from the tank using confined space entrance equipment and a hoist. The victim was pronounced dead at the scene at 10:30 p.m.
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Recommendation #1: Existing tanks should be retrofitted with devices that prevent entry into the tanks.
Discussion: Although there were no witnesses to the incident, there are several theories about what may have occurred to cause the fatal injury. The worker may have reached too far into the tank and fallen, to the bottom, or he may have climbed into the tank to retrieve the cleaning pad and fell either as he descended or when he attempted to climb out. The police investigation noted an imprint of the sole of the worker's shoe on one of the horizontal blades.
The top of the tank was approximately 36 inches above the platform and the worker was 5 feet, 4 inches, tall. It is unlikely that he could have tripped and fallen into the 19-inch opening on top of the domed tank. Although emptied of bakery product, there was fluid at the bottom and product residue on the sides and blades of the tank. Since the incident, the company management has evaluated the area for hazards and retrofitted the tank with two stainless steel rods that were welded to form a cross across the tank opening. Other similar tanks have also been retrofitted. The company has also attached "Danger: Confined Space" signs on the tanks, in English and Spanish, to alert workers that no one should attempt to enter the tanks. Federal OSHA issued no citations to the company for violations of OSHA standards regarding this fatal injury.
Recommendation #2: Employers should conduct a job hazard analysis of all work activities with the participation of the workers.
Discussion: The bakery employed a safety and health consultant to evaluate the facility for hazards and oversee training. In addition, most of the production processes were automated. However, to prevent incidents such as this fall, NJ FACE recommends that employers conduct a job hazard analysis (JHA), of all work areas and job tasks with the employees. A JHA is a procedure that breaks a job or task into specific steps, analyses each step for specific hazards, and uses this information to develop safe work practices to eliminate or reduce those hazards. A JHA should begin by reviewing the work activities for which the employee is responsible and the equipment that is needed. Each task is further examined for mechanical, electrical, chemical, or any other hazard that the worker may encounter. The results of the analysis can be used to design or modify a written standard operating procedure for the job. Additional information is available in the publication, Job Hazard Analysis, which is available on the federal OSHA web site at https://www.osha.gov/Publications/osha3071.pdf.
It is extremely important that employers obtain accurate information on health, safety, and applicable OSHA standards. NJ FACE recommends the following sources of information that should help both employers and employees:
U.S. Department of Labor, Occupational Safety
& Health Administration (OSHA)
New Jersey Public Employees Occupational Safety
and Health (PEOSH) Program
Job Hazard Analysis. US Department of Labor Publication # OSHA 3071, 2002 (revised). USDOL, OSHA/OICA Publications, PO Box 37535, Washington DC 20013-7535. This document can be downloaded from the OSHA Web site at https://www.osha.gov/Publications/osha3071.pdf.
New Jersey FACE Program
Fatality Assessment and Control Evaluation (FACE) Project Investigation # 05-NJ-003
Staff members of the New Jersey Department of Health and Senior Services, Occupational Health Service, perform FACE investigations when there is a report of a targeted work-related fatal injury. The goal of FACE is to prevent fatal work injuries by studying the work environment, the worker, the task and tools the worker was using, the energy exchange resulting in the fatal injury, and the role of management in controlling how these factors interact. FACE gathers information from multiple sources that may include interviews of employers, workers, and other investigators; examination of the fatality site and related equipment; and reviewing OSHA, police, and medical examiner reports, employer safety procedures, and training plans. The FACE program does not determine fault or place blame on employers or individual workers. Findings are summarized in narrative investigation reports that include recommendations for preventing similar events. All names and other identifiers are removed from FACE reports and other data to protect the confidentiality of those who participate in the program.
NIOSH-funded state-based FACE Programs include: Alaska, California, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, New York, Oklahoma, Oregon, Washington, West Virginia, and Wisconsin.
This NJ FACE report is supported by Cooperative Agreement # 5 U60 OH0345-02 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.
To contact New Jersey 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.
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