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Occupational Safety and Health Administration OSHA

Accident Report Detail

Accident: 170618946 - Employee Killed In Fall Into Collection Table Pit

Accident: 170618946 -- Report ID: 0950621 -- Event Date: 01/27/1999
InspectionOpen DateSICEstablishment Name
12583665001/27/19992493Sierra Pine Ltd.
At approximately 7:00 a.m. on January 27, 1999, Employee #1, a millwright with Sierra Pine Ltd., and a coworker were repairing equipment during a bi-monthly shutdown of the fiberboard manufacturing plant. Their second assignment of the day was to blow out the draining hydraulic hoses on a fiberboard press. The hoses drained, by gravity, the hydraulic fluid collected from each of the 38 in. hydraulic rams on the fiberboard press. Working from the main floor level, Employee #1 rolled his tool box to the east side of the press, disconnected all the hydraulic hoses from the central manifold, and then disconnected the hoses from the two jack rams on the east side, as well as the hose from press ram #4. His coworker began on the west side, removing the hoses from the jack ram and from presses #2 and #3. He then tried to reach press ram #1, but was blocked by a jack stand that was being used to hold the press up while the hydraulics were being serviced. The coworker went around the framework of the press and climbed over a guard rail intended to keep employees from falling into the collection pit. He stepped along the outside edge to the hose connection on ram press #1 before returning over the railing. The coworker then went around the press to the east and Employee #1 went around to the west and connected up an air hose to blow the dirt from the hoses. He blew out the hydraulic hoses of the jack rams on the west side, and his coworker started reconnecting the cleaned hoses to the manifold. The coworker thought he saw Employee #1 heading toward fiberboard press ram #1 and then heard a thump and saw the canvas curtain moving. He got up from the manifold and yelled for Employee #1 before observing him lying on the floor in the collection table pit. Employee #1 had fallen approximately 40 ft, suffering massive head injuries. The coworker immediately radioed for emergency help, and other coworkers provided first aid until paramedics arrived. Employee #1 was transported by ambulance to Sutter Roseville Hospital in Roseville, CA, where he was pronounced dead shortly after arriving in the emergency room. The collection table itself was spaced about 19 in. south of the fiberboard press, leaving a large and deep gap. This gap was not fully visible during maintenance repairs because a canvas curtain had been lowered from the ceiling along the south edge of the press to prevent dust and other contaminants from being blown onto the collection table. This created a "false wall" along the south edge of the press where Employee #1 fell.
Keywords: head, maintenance, obstructed view, work rules, millwright, pit, fall, fall protection, unstable position
Employee # Inspection Age Sex Degree Nature Occupation
1 125836650 Fatality Fracture Millwrights

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