FACE Investigation # 02WI011
Hispanic Laborers Drowned In Pond On Golf Course
On June 5, 2002, two male Hispanic laborers drowned after a canoe capsized on a golf-course pond. Victim 1 was working with another laborer trying to sink some tires that were floating on the pond. Neither was wearing personal floatation devices. Victim 1 was the only person in the area who had a radio, and while he left it on the shore, none of the co-workers on shore knew how to use it. One of the co-workers ran to the equipment shed where another employee with a telephone notified emergency services.
The EMS providers arrived within several minutes after receiving the call. Due to the worker’s fear and the inability of workers and responders to communicate effectively, divers began searching the south side of the pond. The co-workers all spoke Spanish and only a few spoke English, so when a co-worker was located who could communicate with the deputy, the sheriff department learned that the victims had not gone into the water on the south side, but rather on the north side. The deputy and two other divers were then sent to the north side. Both victims were soon located, resuscitation efforts were started and both victims were transported to a nearby hospital. Both were pronounced dead upon arrival at the hospital.
The FACE investigators concluded that, to prevent similar occurrences, employers should:
On June 5, 2002, two male Hispanic laborers, ages 22 and 45, drowned after capsizing a canoe on a golf-course pond. On June 6, 2002, the Wisconsin FACE program learned about the incident from a newspaper report. On June 2, 2003, the FACE Director and FACE Field Investigator conducted an on-site visit to the scene of the incident. The incident was reviewed with the General Manager of the golf course. The sheriff’s and coroner’s reports and death certificates were reviewed.
The golf course was in operation for about three years prior to this incident. The 315-acre golf course had a man-made lake, six small ponds and a creek running through the property. The General Manager had worked with the course superintendent and maintenance supervisor (Victim 1) at another golf course for six years before they were employed at the course where the incident occurred. The golf course has a total of 80 employees with 23 ground crew members. The grounds crew is primarily Hispanic. Most of the crew goes to Mexico during the winter and returns to the golf course from approximately March to mid-November. Victim 1 was fluent in English and Spanish and was one of three employees who translated from English into Spanish for the other workers. The Superintendent and the General Manager also knew a little Spanish.
Employees primarily received on-the-job safety training. The company’s worker’s compensation insurance company provided the golf course with safety manuals specific to golf courses and on working with Hispanic employees. Training videos were available in English and Spanish. The Golf Course Superintendent’s of America Association provided job descriptions in English and Spanish. The General Manager encouraged non-Spanish speaking employees to take Spanish classes at a community technical school to enhance communication between all the workers. An interpreter participated at the monthly safety meetings. Bi-lingual safety signage was posted in the shop where the safety equipment was stored. All grounds team workers received training on evacuation procedures, machine safety, hazardous weather conditions, and personal protective equipment. New employees received a general orientation specific to this particular golf course. Following the initial training, a buddy system was used by assigning an inexperienced employee to work with an experienced worker. Cross training was emphasized so that most workers could perform the majority of tasks needed at the course.
The Superintendent, General Manager and Victim 1 each kept a two-way radio close at hand during the workday for routine and emergency communication. The co-workers knew who carried the radios.
This golf course had a fish hatchery license and workers stocked the pond with fish. They built a sunken fish crib in the pond using large tractor tires, pallets, and other submersed items. Occasionally the tires that were used as the crib would float to the top of a pond. This was aesthetically displeasing to the golfers. On the day of the incident, the manager directed the workers to use a chain saw to cut a five-foot diameter tire that was floating on the pond and sink it to the bottom of the pond. Victim 1 and a grounds crew laborer were assigned to complete the task. They used a 17-foot aluminum square stern canoe with a 2 horsepower motor. No paddles were available in the canoe. The laborer and Victim 1 were both wearing lightweight jackets, work shirts, long pants and heavy work boots. Neither worker was wearing a personal flotation device (PFD), nor were there PFD’s or flotation devices available in the canoe that could be used or thrown to a victim.
The laborer sat in the front of the canoe while Victim 1 sat behind him controlling the motor. They reached the floating tire and began to try to cut it, but the tire and canoe continued to move so they tied a rope around the tire and towed it to the shore. While on the shore, the laborer cut the tire with the chainsaw and then hooked the tire behind the canoe. Victim 1 (in the canoe) towed the tire out further into the pond. The laborer sat behind the canoe on the tire. They untied the tire and Victim 1 moved the canoe around to pick up the laborer and turned off the motor. The laborer was still holding onto the tire and trying to climb into the canoe with the help of victim 1. The canoe flipped and Victim 1 fell out. They were unsuccessful in their attempts to upright the canoe. The laborer stayed with the canoe and encouraged Victim 1 to also grab onto the canoe, but Victim 1 grabbed onto the tire and said he was fine. The laborer holding onto the canoe approached the shore. By then, several of the grounds keepers had gathered on the shore. They were shouting and laughing while Victim 1 told them that he was alright. Victim 1 then began to struggle and call for help and disappeared under the water.
One of the grounds crew (Victim 2) who was mowing grass near the pond, jumped off his tractor when he realized what was happening and ran into the water to help Victim 1. Victim 2 also disappeared under the water. Victim 1, was one of three golf course staff who usually carried a two-way radio. He left the radio on the shore when he went out into the canoe. Few of the co-workers present spoke English and none of them knew how to operate the radio. One co-worker ran to the equipment shed where another employee with a telephone was located. The other employee notified Emergency Medical Services (EMS).
This golf course straddles two townships about a mile from the closest city. Emergency providers from both townships plus three dive teams from the city responded. They began arriving on the scene about 12:48 p.m., only several minutes after receiving the call. The divers began searching the south side of the lake. The co-workers all spoke Spanish, so when a sheriff deputy who spoke rudimentary Spanish began interviewing co-workers, he learned from one employee who spoke a little English, that the victims had gone into the water on the north side. The deputy and two other divers were then moved to that area.
The pond varies from 8-15 feet deep. The first victim was found about 1:19 P.M. and at 1:22 P.M. they found the second victim. Both were approximately 20-25 feet out in 8-10 feet deep water. Resuscitation efforts were started and both victims were transported to a nearby hospital. Both were pronounced dead upon arrival at the hospital.
Cause Of Death
The cause of death for both victim 1 and victim 2 was asphyxia as a consequence of drowning.
Recommendation #1: Employers should ensure U.S Coast Guard-approved personal flotation devices are available and used when an employee works on, near or over water where the danger of drowning exists.
Discussion: Whenever employees are working over or near water where the danger of drowning exists, a U.S. Coast Guard approved life jacket or buoyant work vest should be worn. If the victims in this incident had been wearing approved personal flotation devices, they probably would have remained at the surface of the water and been safely rescued by their co-workers or by emergency personnel who were called to the scene. While the floatation devices were available in the storage area, they were not used. Throwable floatation devices were also not available. Employers must ensure that employees receive training about the use of Personal Floatation Devices (PFD’s) and that PFD’s are available and worn at all times when working near water.
Recommendation #2: Develop, implement and enforce a comprehensive written safety program for all workers that includes training in hazard recognition and the avoidance of unsafe conditions when using small water craft.
Discussion: Employers should evaluate all tasks performed by workers, identify all potential hazards, then develop, implement and enforce a written safety program addressing these hazards. Training should be included about the hazards and safe work practices that apply to the work employees are expected to perform. Additionally, training in recognizing and avoiding the potential hazards should be given to all workers. Employers should assess the competence of workers in the recognition of hazards and safe work practices. The victims had not received training regarding water safety and small craft safety. They had no paddles available. With training in safety they would have been taught what to do if the canoe overturns, how to upright it and the importance of staying with the canoe once it has flipped over.
Recommendation #3: Train employees on how to use two-way radios for emergency communication.
Discussion: While every worker does not carry a radio, knowing how to use one may save time in seeking help. Consider having at least one person with access to a radio in every group of workers within an area so they do not have to go far for help in an emergency. In this case, the victim left his radio on the shore and no one knew how to use it. If the victim had taken the radio with him, one would not have been available for use.
Recommendation #4: Train non-English speaking workers about emergency situations and the role of law enforcement and/or rescue services in order to reduce anxiety when emergency contact with official agencies occurs.
Discussion: During the investigation it was noted that perhaps the men were afraid of talking with uniformed officers and the rescue personnel. Initially, two of the three diving teams were looking on the wrong side of the lake for the victims. When the deputy who spoke a little Spanish was able to communicate with one of the workers, he had that individual throw a stone into the area where they observed the victims go under the water. The diving teams needed to move to the opposite shore. With the correct information, the diver went to the location where the stone was thrown and found victim 2 within minutes and then victim 1 four minutes later. Part of orientation for workers from other countries who may have fears about the law should include presentations by those agencies explaining what their purpose is in the community and what their duties are that protect and aid individuals in need.
Recommendation #5: Develop and implement a program that would remind all employers who must call for emergency services to request an interpreter for a specific language when a substantial immigrant population is employed or present at a worksite.
Discussion: In this case having an interpreter present with the emergency rescue team could have made a difference in the time that it took to search the correct area of the pond. Training all staff at the worksite to request an interpreter when requesting assistance in an emergency should be done. (i.e. include as part of the orientation, place reminder stickers on telephones and radios, etc.)
Wisconsin Fatal Assessment and Control Evaluation (FACE) Program
Staff members of the FACE Project of the Wisconsin Division of Public Health, Bureau of Occupational Health, conduct FACE investigations when a machine-related, youth worker, Hispanic worker, highway work-zone death, farmers with disabilities or cultural and faith-based communities work-related fatality is reported. The goal of these investigations is to prevent fatal work injuries studying: the working 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.
To contact Wisconsin 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.