Inspection Detail

Inspection: 125493411 - Sf-Recreation & Parks Department

Inspection Information - Office: San Francisco District Office

Investigation Summary

On November 30, 2006, Employee #1, a gardener, was driving and operating a two-axle Packer truck, 1988 Ford 8000 Diesel, E482347, with a 13-yard, rear-loaded compaction equipment, Leach Packmaster (Model Number: S-III-13-Y; Serial Number: S-III-1020). As part of her regular assignment, she drove to Cayuga Park to pick up brushes from that park. Another gardener, assigned to this park, was loading the hopper, while Employee #1 was standing on the riding step and was activating the packer lever to activate the packing cycle. At approximately 9:30 am, Employee #1 initiated the compaction cycle by moving the packing lever forward with her right hand, while holding the top grab handle with her left hand. Contrary to the instruction in the manual, which required to move a packer lever forward and then let it go, she had to hold the lever in that position until the packing plate reached the interrupted position, above the pinch point. The lever then kicked back to its neutral position. She then moved the lever forward for the second step of the compaction cycle. Again, the lever had to be held in the forward position, in contrary to the manufacturer's instruction. At that step, the rollers that the packer plate rode on, popped into tracks along the hopper edge, creating a pinch point before the packer plate reached the bottom of the hopper. It was at that moment that Employee #1 felt she was poked in the crotch and leg by a piece of brush. In response, she moved her left hand from the grab handle and placed it on the edge of the hopper opening to steady her body, while releasing her right hand from the lever to push the brush away. At that point, the packer blade struck the top of her index and middle fingers, amputating a tip of her index finger and injuring the middle finger. Employee #1 then moved the lever rearward to release her crushed fingers from the packer blade. She was taken to San Francisco General Hospital by another gardener, where she underwent the first reconstruction surgery on her two fingers. She had two additional surgeries on her index finger during the following month. The investigation revealed that the compaction cycle could not be activated and completed in accordance with the manufacturer's design and operating instructions which repeatedly warn the Operator not to hold the packer lever in position and to stand clear of the hopper area, Point of Operation, during the packing cycle. Rather, the Operator had to stand next to the hopper area to hold the packer lever in position throughout the whole compaction cycle. It was therefore determined that the serious injury was caused by not complying with the manufacturer's recommendations.

Keywords: KICK BACK, AMPUTATED, FINGER, ROLLER--MACH/PART, CAUGHT BETWEEN, TRUCK, STRUCK BY, BLADE, HAND, HOPPER