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59-Year-old male worker at a fruit storage facility died after entering a controlled atmosphere storage room.
Michigan State University
Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 08MI121, 2010 Jun; :1-16
In the fall of 2008, a 59-year-old male employee at a fruit storage facility located on a farm died after entering a controlled atmosphere (CA) apple storage room. Its atmosphere contained less than 3% oxygen (O2). The storage room had a large wooden outer door (cooler door) and an interior aluminum door, which had been sealed with caulking and weather stripping and which had a Danger, Do Not Enter sign affixed. To maintain the atmosphere but still allow for visual observation of the produce, the door to the CA room had a 2- by 3-foot Plexiglas window attached to the door by 18 bolts/wing nuts. The event was un-witnessed. The decedent removed the wing nuts and the Plexiglas window and climbed through the door opening, and entered the CA room. The owner found him collapsed on the floor on his knees with his head leaning against an apple bin. A bag of apples was found next to his body. The owner leaned through the window opening into the CA room, grabbed the decedent by his coat, pulled him toward the door through the window opening, and checked for a pulse. He did not find a pulse. The owner left the area to call the farm office to have them call for emergency response. Upon returning to the decedent, he took a deep breath, leaned through the window opening, grabbed the decedent under his arms and pulled him through the window opening and out of the CA room. The owner attempted CPR after he pulled the decedent out of the CA room but was unsuccessful in resuscitating him. Emergency response arrived and he was declared dead at the scene. A bag of a different type of apple obtained from another CA room was found on the propane-powered forklift that was parked in the aisleway nearby. The Plexiglas window was found leaning against a wall with the wing nuts nearby. Recommendations: Recommendations that directly address the factors contributing to the fatality: 1.) Evaluate the workplace to determine if a confined space and/or permit-required confined space (PRCS) is present. If a PRCS is/are present, the commercial facility owner and/or farmer should develop and implement the necessary sections of MIOSHA Occupational Health Standard Part 490, Permit-Required Confined Space and MIOSHA Safety Standard, Part 90, Confined Space Entry. 2.) The employer should develop and implement a written safety and training program that includes the MIOSHA Right-to-Know standard (Parts 92 and 430). 3.) Controlled atmosphere generating equipment and door manufacturers should include a confined space warning sign(s) on the equipment/door exterior. Recommendations to commercial fruit and vegetable storage and warehousing facilities and to farmers storing fruits and vegetables in a similar way: 4.) Instruct employees/family members/visitors not to enter a confined space or other designated area to rescue an ill/injured individual unless trained and equipped with appropriate rescue equipment. 5.) Utilize electric forklifts when loading and unloading product in a controlled atmosphere (CA) room. 6.) Maintain and tune propane-powered forklifts for operations associated with CA rooms and any interior building use. If the forklift was manufactured prior to 2007, equip the forklift with a catalytic converter to further minimize carbon monoxide (CO) emissions, or lease/use a forklift manufactured after 2007. Since neither good maintenance nor a catalytic converter eliminate all carbon monoxide, this approach is not as effective as switching to an electric forklift. 7.) If propane-powered forklifts are used to load and unload product from a CA room, ensure the ventilation equipment in CA rooms is operating. Conduct air monitoring to determine the CO concentration in the room to protect the forklift operator from an overexposure. Consider using direct reading CO monitors (room or personal). 8.) Place oxygen and carbon monoxide air monitoring air portal lines or equipment at various locations in the CA room to better characterize the atmosphere in the room. 9.) Alert employees/family members/visitors to the hazard of sealed storage areas even when no oxygen drawdown has been done. These areas may have lower oxygen levels than expected. 10.) Establish a CA room opening procedure to minimize inhalation hazards posed by low oxygen levels. Editor's Note: Operations involved with agricultural commodities need to determine the "industry" status of the work activities within their operations. The same work activity can be either "Agricultural" or "General Industry" and be covered by different regulations. For the purposes of this report an "agricultural operation" means the work activity designated in major groups 01 and 02 of the Standard Industrial Classification manual, United States Bureau of the Budget, 1972 edition. Agricultural operations include any practices performed by a farmer or on a farm as an incident to or in conjunction with farming operations including preparation for market, delivery to storage or market, or to carriers for transportation to market. Individual state definitions may vary. Recommendation to MSU Extension: 11.) Update the Controlled Atmosphere Storage and Warehousing Clinic manual to comply with MIOSHA health and safety standards.
Region-5; Accident-analysis; Accident-potential; Accident-prevention; Accidents; Agricultural-industry; Agricultural-machinery; Agricultural-processes; Agricultural-workers; Confined-spaces; Control-equipment; Controlled-atmospheres; Control-methods; Control-systems; Control-technology; Injuries; Injury-prevention; Occupational-accidents; Occupational-health; Occupational-safety-programs; Protective-equipment; Protective-measures; Safety-education; Safety-engineering; Safety-equipment; Safety-measures; Safety-personnel; Safety-practices; Safety-programs; Training; Warning-systems; Work-analysis; Work-areas; Work-operations; Work-performance; Work-practices; Author Keywords: Confined Space; Oxygen Deficiency; Controlled Atmosphere Storage; Agriculture
Field Studies; Fatality Assessment and Control Evaluation
NTIS Accession No.
National Institute for Occupational Safety and Health
Michigan State University
Page last reviewed: April 12, 2019
Content source: National Institute for Occupational Safety and Health Education and Information Division