California Department of Health Services
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SUMMARY : CASE
192-207-01
A farm
worker was driving a mechanical harvester in a fig orchard.
This harvester swept up the figs from the orchard ground.
Then, a conveyor belt carried the figs past a big fan on the
side of the machine which blew the dirt off them. A metal
cover guarded the fan blades, but not the fan's exhaust outlet.
Before his lunch break, the worker left the fan running and
stood in front of the exhaust outlet, blowing the dirt and
dust off his clothing. His foot entered the exhaust outlet
to where it could touch the fan blades, about nine inches
inside. The fan blades amputated his foot below the ankle.
A co-worker
turned off the harvester, and the worker's foreman called
911 from a truck. Paramedics took the worker and his severed
foot to the hospital. The foot was too mangled for doctors
to sew back on. Later, doctors amputated his left leg below
the knee so he could use an artificial leg.
How
could this injury have been prevented?
- Employers
should put guards wherever a person can touch moving equipment.
- Workers
should use machinery only for the purposes for which it
was designed, and for which safety training has been given.
BACKGROUND
On July
16, 1992, NURSE staff identified an injury which occurred
in a fig orchard while reviewing records at a Level 1 Regional
Trauma Center. On July 6, 1992, a farm worker was operating
a mechanical harvester. Before taking his lunch break, the
worker stood in front of the harvester's exhaust blower fan
to blow dust off his clothing. He removed his left shoe to
blow dust off his socks. His left foot touched the unguarded
part of the fan in the exhaust outlet and was amputated below
the ankle.
A nurse
from the NURSE Project interviewed the injured worker by telephone
on August 5, 1992. The NURSE Project's Senior Safety Engineer
evaluated a similar harvesting machine on August 12, 1992,
and was able to inspect the mechanical harvester actually
involved in the incident on October 2, 1992. At this time,
he also discussed the incident with the farm owner/operator.
The
farm owner/operator did not notify the California Occupational
Safety and Health Administration (Cal/OSHA) of the incident.
Cal/OSHA was later informed of the incident, however, they
did not investigate the injury.
The
incident took place in a fig orchard owned by a family corporation.
The farm grows only figs, on approximately 120 acres, and
owns two identical mechanical harvesters. The farm employs
5 full-time workers and 40 casual workers (working 1-12 weeks
per year).
The
Senior Safety Engineer reviewed the farm's written safety
program and found that, although it addressed all seven points
required by Title 8 California Code of Regulations 3203 --
Injury and Illness Prevention Program, the program was not
being carried out at the time of the incident. (As of July
1, 1991 the State of California requires all employers to
have a written seven point injury prevention program: 1. designated
safety person responsible for implementing the program; 2.
mode for ensuring employee compliance; 3. hazard communication;
4. hazard evaluation through periodic inspections; 5. injury
investigation procedures; 6. intervention process for correcting
hazards; and 7. a health and safety program.)
The
Senior Safety Engineer noted that the farm did not conduct
periodic inspections for hazards on the job, and did not conduct
safety inspections of equipment. New and returning employees
were not given safety training, and there were no regular
safety meetings documented in the farm's safety records.
The
injured worker had many years of experience harvesting figs
and had operated this mechanical harvester for approximately
ten years. The farm had purchased the mechanical harvester
new about twenty years ago. The worker stated that he had
received training in the operation of the mechanical harvester
from the foreman, but had not received safety training. The
worker's training was not documented in the owner/operator's
records.
INCIDENT
On July
6, 1992, at approximately 12:08 p.m., the Emergency Medical
Services (EMS) responded to a 911 call for assistance. Upon
arrival two minutes later EMS found a 29 year-old Hispanic
male lying on the ground beneath a tree, 15 feet from a mechanical
harvester. His foot had been amputated by the fan on this
mechanical harvester.
The
injured worker had been re-hired for the season ten days before
this incident. He operated a mechanical harvester in a fig
orchard. The machine sweeps the figs from the orchard ground
into an auger conveyor system that drops them onto a wire
mesh conveyor belt. The conveyor belt carries the figs past
a high volume blower fan, which blows the dust, leaves, and
branches off the figs and out an exhaust outlet. After the
figs are blown clean, the conveyor system drops them into
large boxes, which are pulled on a trailer behind the harvesting
machine. One operator steers the machine from the front, while
a second employee rides the trailer at the rear, sorting and
distributing the figs as they are deposited in the field boxes.
The injured worker was steering the machine on the day of
his injury.
At 11:48
a.m., just before his lunch break, the worker climbed down
from the mechanical harvester. He stood in front of the exhaust
outlet of the machine's blower fan to blow the dust off his
clothing. The blower fan is mounted on the side of the harvesting
machine. It is approximately four feet in diameter, with dull
metal blades. The fan takes in air from the top of the machine,
and blows dirt and debris out the exhaust at the bottom. The
blower fan is mounted inside a fan housing (metal cover),
which shields the fan blades except at the exhaust outlet
at the bottom of the fan. The fan blades are located approximately
nine inches inside the exhaust outlet.
The
injured farm worker did not remember the incident clearly.
He had taken off his left shoe to blow dust off his socks.
His foot entered the exhaust opening far enough to touch the
fan blades, and the blades amputated his foot at the ankle.
The
farm worker called for help. When his co-worker arrived, the
injured worker told him how to turn off the fig harvesting
machine. The co-worker then ran to notify the foreman, who
called 911 from his truck. The EMS arrived at 12:10 p.m.,
about twenty minutes after the incident and two minutes after
being notified. EMS elevated the injured foot, controlled
the bleeding, administered oxygen and established an IV of
lactated ringers solution. After retrieving the worker's amputated
foot, they left the orchard fourteen minutes after arrival
on the scene. EMS transported the injured worker to the Level
I Regional Trauma Center, arriving about twenty-seven minutes
after leaving the orchard.
At the
trauma center, the injured part of the worker's lower leg
was cleaned and a tourniquet was applied. The worker was taken
up to the operating room to control bleeding. The severed
foot could not be surgically reattached because of extensive
tissue damage. Four days later he was transferred to local
acute care hospital for insurance purposes.
On September
30, 1992, in a follow-up call, a nurse from the NURSE Project
learned that the injured worker had undergone an operation
to amputate his left leg below the knee, in order to provide
an attachment point for a prosthetic device. The worker had
received his prosthesis and was undergoing physical therapy.
PREVENTION STRATEGIES
- Employers
should instruct employees in how to use equipment safely,
and to use it only for the purposes for which it was designed.
This employee was not formally instructed in the safe operation
of the mechanical harvester. He also used the machine's
fan to dust off his clothing, a purpose for which it was
not designed. Had the employee been instructed to use the
machine only for operations in which he had been trained,
this incident might not have occurred.
- Equipment
should be designed with safety engineering in mind. In this
incident, the mechanical harvester was over twenty years
old, and had not been manufactured with a guard over the
exhaust fan outlet. Employers should reassess old equipment
before the harvest season begins, and retrofit it with safety
features. The inspection should include the proper placement
of guards on rotating shafts, gear drives, chain and sprocket
drives, shear points and other possible contact points with
moving equipment. In this incident, if the exhaust fan outlet
had been fitted with a guard, the worker may not have been
injured*. *Title 8 California Code of Regulations 4002 (a):
All machines, parts of machines, or component parts of machine
which create hazardous revolving, reciprocating, running,
shearing, punching, pressing, squeezing, drawing, cutting,
rolling, mixing or similar action...shall be guarded.
FURTHER INFORMATION
For further
information concerning this incident or other agriculture-related
injuries, please contact:
NURSE
Project
California Occupational Health Program
Berkeley office:
2151 Berkeley Way, Annex 11
Berkeley, California 94704
(510) 849-5150
Fresno
office:
1111 Fulton Mall, Suite 212
Fresno, California 93721
(209) 233-1267
Salinas
office:
1000 South Main St., Suite 306
Salinas, California 93901
(408) 757-2892
Disclaimer
and Reproduction Information: Information in NASD does not
represent NIOSH policy. Information included in NASD appears
by permission of the author and/or copyright holder. More
NASD Review: 04/2002
This
document,
CDHS(COHP)-FI-92-005-21
,
was extracted from a series of the Nurses Using Rural Sentinal
Events (NURSE) project, conducted by the California Occupational
Health Program of the California Department of Health Services,
in conjunction with the National Institute for Occupational
Safety and Health. Publication date: December 1992.
The
NURSE (Nurses Using Rural Sentinel Events) project is conducted
by the California Occupational Health Program of the California
Department of Health Services, in conjunction with the National
Institute for Occupational Safety and Health. The program's
goal is to prevent occupational injuries associated with agriculture.
Injuries are reported by hospitals, emergency medical services,
clinics, medical examiners, and coroners. Selected cases are
followed up by conducting interviews of injured workers, co-workers,
employers, and others involved in the incident. An on-site
safety investigation is also conducted. These investigations
provide detailed information on the worker, the work environment,
and the potential risk factors resulting in the injury. Each
investigation concludes with specific recommendations designed
to prevent injuries, for the use of employers, workers, and
others concerned about health and safety in agriculture.
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