UNITED STATES
DEPARTMENT OF LABOR

At 11:50 a.m. on February 24, 2022, an employee was working as the plant electri cian for a firm that produced roasted nuts and made almond butter. He was workin g with electrical equipment in the butter/grinding room. The employer was instal ling new equipment for this operation, including an A.C. Horn milling machine, w ith serial number SN33 988R. The firm's engineering team had asked the employee to determine why the ISM laser management tool on top of the machine's hopper wa s providing incorrect readings. The laser was attached to a bung welded to the h opper. The employee saw that he had to bend the bung, as it was not level. He bo rrowed a 30 inch (760 mm) pry bar from a coworker and climbed a 6 foot (1.8 mete r) ladder up to the fourth rung, or approximately 4 feet (1.2 meters). The layou t of the equipment would not let the employee position the ladder perpendicular to the equipment and let him get closer to the sensor, so he placed the ladder p arallel to the equipment. At this angle, he had to twist to his right to place t he pry bar under the bung. A video of the incident showed that he had both hands on the pry bar, applying a lot of force. As he was pulling down on the pry bar, it slipped. He fell approximately 6 feet (1.8 meters) from the ladder or machin ery to the floor. He initially landed on his feet but fell to the floor and fina lly onto his right side. He suffered a compression fracture of his L4 vertebra a nd was hospitalized. He had experienced prior issues with his back. The employe r claimed that due to the tight quarters, there was no other way to safely acces s the bung and sensor. During an inspection, the CSHO noticed a scissor lift nex t to the equipment. A subcontractor doing electrical work on the equipment had b rought it in. After the incident, the employer completed a job hazard analysis f or the sensor replacement, as required by their written safety program. The use of a scissor lift was made a requirement for changing out the sensor.