On February 11, 2003, a 42 year-old male material handling operator, who was employed at a coal-fired electrical generating plant, sustained fatal injuries as a result of falling 15 feet through a steel grid into an underground coal cracker. On the morning of the incident, coal from an emergency stockpile was transported through a ground opening that was covered by a steel grid called a "grizzly"(14' X 14') with 12" by 12" grid openings. Under the grizzly there was a 15 feet deep hopper, a coal cracker, and a second hopper that was 12 feet deep connected to a conveyor belt. On January 22nd, nineteen days before the fatal incident, an operator had recorded damage to the grizzly in the team's daily log: the steel bars (1"X 10") that formed the grids were broken and bent resulting in a 2' by 2.5' hole in one corner of the grizzly. A decision was made within the team not to repair the grizzly until spring. On the morning of the incident, the victim was seen by two of his co-workers (an operator and an engineer) walking on the grizzly with a shovel in his hand. It appeared that the victim was using the shovel to break the frozen coal and clear the clogged grids. Then, at approximately 9:18 AM, the engineer noticed that the shovel was left on the grizzly but the victim was gone. He immediately told the operator to shut down the coal transporting system. The victim was found on the conveyor belt 50 feet away from the grizzly. The victim apparently fell through the hole on the damaged section of the grizzly into the hoppers and the frozen coal cracker and was carried out by the conveyor belt. The operator immediately called an incident commander in the plant's master control room. The incident commander summoned an ambulance that arrived at the site in ten minutes. The victim was transported to a local hospital where he was pronounced dead. New York State Fatality Assessment and Control Evaluation (FACE) investigators concluded that to prevent similar incidents from occurring in the future, employers should: 1. Repair damaged equipment in a timely manner, and place warning signs and guards immediately on and around the damaged equipment to warn workers of the safety hazard; 2. Develop standard procedures for emergency situations in which employees may have to walk on a grizzly and mandate the use of personal fall arrest systems; and 3. Evaluate the effectiveness of current plant occupational safety and health management structures and establish a system that anticipates problems and provides clearly defined responsibilities and accountability.
Region-2; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-areas; Work-performance; Work-practices; Safety-education; Safety-equipment; Safety-measures; Safety-monitoring; Machine-guarding; Machine-operation; Personal-protection; Personal-protective-equipment; Protective-equipment; Warning-devices; Warning-signs; Electric-power-generation