Inspection Detail

Inspection: 1587701.015 - Ready Roast Nut Company, Llc.

Inspection Information - Office: Fresno District Office

Investigation Summary

At 11:50 a.m. on February 24, 2022, an employee was working as the plant electrician for a firm that produced roasted nuts and made almond butter. He was working with electrical equipment in the butter/grinding room. The employer was installing new equipment for this operation, including an A.C. Horn milling machine, with 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 was providing incorrect readings. The laser was attached to a bung welded to the hopper. The employee saw that he had to bend the bung, as it was not level. He borrowed a 30 inch (760 mm) pry bar from a coworker and climbed a 6 foot (1.8 meter) ladder up to the fourth rung, or approximately 4 feet (1.2 meters). The layout 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 parallel to the equipment. At this angle, he had to twist to his right to place the 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 machinery to the floor. He initially landed on his feet but fell to the floor and finally onto his right side. He suffered a compression fracture of his L4 vertebra and was hospitalized. He had experienced prior issues with his back. The employer claimed that due to the tight quarters, there was no other way to safely access the bung and sensor. During an inspection, the CSHO noticed a scissor lift next to the equipment. A subcontractor doing electrical work on the equipment had brought it in. After the incident, the employer completed a job hazard analysis for 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.

Keywords: Back, Fall, Fall From Elevation, Food processing, Fracture, Injury Illness Prevention Program, Ladder, Pry Bar, Reaching From Ladder, Scissor lift, Slip, Spine, Vertebra, Work Rules