Incident Description

On September 6, 2017 a significant workplace safety incident occurred at ABC Company. A

journeyman electrician (Tony Lee), who had worked for ABC Company for 20 years, suffered
multiple injuries as a result of falling out of an elevated boom-lift basket.

Earlier that year, the ABC Company had purchased the 2017 model year, slightly used, boom-type
elevating work platform. In June, the worker, Tony Lee, was sent to a one-day “train the trainer”
course offered by the work platform’s manufacturer, the Big Boom Lift Company. The course
consisted of 4 hours of classroom time and 4 hours of hands-on training for the lifts.

On September 6, 2017 Tony was told by his supervisor, Ellen Proto, to change some burned-out
yard lights. At 9:30 am Tony was seen moving the big boom lift across the yard. Then, at 10:30 am
he was found lying on the ground under the lift. The basket from the lift was elevated
approximately 25 feet in the air.

Subsequent investigation revealed that when Tony and the other operators had used the lift prior
to that incident, they’d occasionally felt a bit of a clunk, but didn’t attach much importance to
this, since the lift was virtually new and they assumed the problem would simply work itself out.
In fact, there was a nut on the back of one of the leveling cylinders that had unthreaded itself
(this caused the clunk). The September 6 incident occurred when the nut had unthreaded itself to
the point where it let go and the basket tipped, spilling the worker.
 WITNESS STATEMENT

Date: Sept 6 2017 Time: 13:35

Location: Sawmill
Statement of: Robert Black
Address: 2345 Wright Road
Phone (h): 250-555-3456 Phone (w): 250-555-1234 Other:
Occupation: Cut-Off Saw Operator
Statement taken by: OSO (Occupational Safety Officer)

OSO: Mr. Black can you tell me in your own words what you witnessed this morning?
RB: Well it was just after coffee about 9:30 or so when I saw Tony Lee moving the new lift into position at the base of the light pole
to the north of my operator’s booth. The next thing I saw was Tony up in position next to the light fixture. The lights had been out
for quite a while. I looked away for a while and when I looked back I saw the lift basket at a weird angle, but Tony wasn’t there.
Then I heard a commotion on the radio. I think it Jana the forklift operator was calling for first aid. He said Tony had fallen out of
the basket and was hurt. I shut down the cutoff saw and went to see if I could help. I used to have my first aid ticket but it’s not up
to date now.
OSO: Did you notice if Mr. Lee was wearing any fall protection equipment at the time of the accident?
RB: Yeah, Tony always wears his gear.
OSO: Did you notice if he was wearing the fall protection equipment this time?
RB: I think so. The harness he wears is orange.
OSO: Did you notice whether his lanyard was attached to an anchor point?
RB: No I didn’t. I wasn’t paying that much attention.
OSO: To your knowledge does Tony normally operate the lift?
RB: Tony is the guy they sent out to get trained on the new lift although I have seen other guys operate the unit. We used to have
an old scissor-type lift which didn’t work very well.
OSO: Do you recall whether Tony or the other operators of the old lift wore fall protection equipment when in use?
RB: I don’t think so. It had a large platform and was equipped with guardrails all the way around. But I saw Tony using the
harness and lanyard when he was working on top of the mill roof about a month or so ago.
OSO: Is there anything else you’d like to add to this statement?
RB: No thanks.
Statement Concluded 14:25
 WITNESS STATEMENT

Date: Sept 6 2017 Time: 12:30

Location: Sawmill
Statement of: Jana Dhaliwal
Address: 4545 34B Street
Phone (h): 250-555-1212 Phone (w): 250-555-1234 Other:
Occupation: Forklift Operator
Statement taken by: OSO (Occupational Safety Officer)

OSO: Mr. Dhaliwal can you tell me in your own words was you witnessed this morning?
JD: I was coming around the corner of the mill and saw Tony Lee moving the new lift around the corner of the planer. He was
going slow and had the basket close to the ground. I stopped and waited for Tony move past me, then continued on.
OSO: Was Mr. Lee wearing fall protection equipment at this time?
JD: He was wearing a harness but I couldn’t tell whether he was attached to anything. The guys don’t like to use any fall
protection in the lifts. I’ve seen them before, and they haven’t been wearing any gear at all.
OSO: Have you seen Mr. Lee operate this lift before?
JD: Yes, Tony is the one they sent out to get trained and he’s the one that normally operates the equipment.
OSO: Is this machine new to the site?
JD: Yes, we had an old scissor lift but it didn’t get into all the locations, so they bought a new one that could access all the areas.
OSO: What did you see when you came back around the corner of the mill?
JD: Tony had pulled the lift under one of the yard lights, which had been out for a while – the guys had been complaining for a
number of months about the lack of lighting in the yard. I saw the basket in the air about 25-30 feet or so, but the basket was on a
funny angle. Then I saw Tony lying on the ground at the base of the light pole face down. He wasn’t moving so I called first aid on
the radio and went over to see if I could help.
OSO: Was Mr. Lee conscious when you arrived?
JD: Yes, but he was in a lot of pain and was complaining of his wrists, head, and legs.
OSO: What did you do then?
JD: By that time the first aid attendants had arrived and I just got out of their way and helped with the stretcher and spine board.
OSO: Was Mr. Lee wearing any fall protection equipment when you attended him at the base of the pole?
JD: Yes, he was wearing a body harness and both ends of a lanyard were clipped to the ring on the back.
OSO: Is there anything else you would like to add to this statement?
JD: No.
Statement Concluded 13:20
 WITNESS STATEMENT

Date: Sept 6/2017 Time: 15:20

Location: Mill
Statement of: Ellen Proto
Address: 2121 Hill Road
Phone (h): 250-555-9876 Phone (w): 250-555-1234 Other:
Occupation: Maintenance Supervisor
Statement taken by: OSO (Occupational Safety Officer)

OSO: Ms. Proto, please tell me in your own words what happened this morning?
EP: Well I was in early about 5:30 am or so preparing for our Management Meeting at 8:30 am. Tony Lee, one of our electricians,
came by my office about 7:30 and we reviewed the repairing of the yard light. We discussed the job, the location of the new lights
and that I wanted to be sure we had traffic cones up when using the lift in the yard. I was just getting out of the management
meeting at about 10:30 when I heard the first aid call on the radio. I went over to the accident scene to see if I could help.
OSO: Are you familiar with the operation of the lift?
EP: I’m familiar with the use of the equipment, but I’ve never operated either the old lift or the new big boom lift.
OSO: Who does the education and training on the use of the lifts on this site?
EP: Tony Lee was sent out to a one-day Train the Trainer Course on June 7 put on by Big Boom Lift Company prior to the new
lift arriving on site. Tony does all the training. He’s certified. We’ve got a copy of his certificate.
OSO: Has Tony trained anyone else on the use of the lift?
EP: Yes, I think he’s trained a couple of other of the maintenance crew on the use of the equipment. I’ve seen a couple of other
guys using it.
OSO: Did you see Tony using the lift this morning?
EP: No, as I said, I was really busy getting ready for the management meeting. Then all hell broke loose this morning when the
mill started up. I barely had time to talk with Tony and tell him where the new lights were stored.
OSO: Have you seen Tony use the lift any time in the past?
EP: Yes, a lot of times.
OSO: Was Tony wearing his personal protective equipment while operating the lift?
EP: Yes, Tony’s good about wearing his safety gear.
OSO: Do you recall whether Tony was wearing his fall protection equipment when you saw him use the boom lift?
EP: He must have, but I really can’t remember.
OSO: Do you have any records or documentation on the education and training of Mr. Lee?
EP: Most of the records are maintained by Human Resources.
OSO: Do you have any records of supervision for Tony or any other workers under your direction and control?
EP: I keep a daily journal of my conversations and observations with the workers. All the supervisors do periodic written checks
on the workers. I don’t have anything for Tony. He was the trainer. I don’t know anything about lifts.
OSO: Is there anything else you’d like to add to this statement?
EP: No thanks.
 WITNESS STATEMENT

Date: Sept 7/2017 Time: 13:00

Location: Hospital
Statement of: Tony Lee
Address: 233 Redding Road
Phone (h): 250-555-3434 Phone (w): Other: 250-555-1234
Occupation: Electrician
Statement taken by: OSO (Occupational Safety Officer)

OSO: Mr. Lee can you tell me what happened the morning of Sept 6, 2017?
TL: Well I started work at 7:00 am. I got my tools ready and fueled up the new lift, then met with my boss Ellen Proto. I was starting
the lights in the mill yard today as part of our annual PM of the lights. There were quite a few lights that were not operating. I met
with Ellen and we discussed the job and the location of the new lights. Ellen indicated that she wanted me to use traffic cones
around the lift when I was operating around mobile equipment. By the time I got everything organized and answered a couple of
radio calls it was about 9:30 when I finally got going. I pulled the unit up to the light pole to the north of the cut-off saw and started
to move the work platform into position. I just started to pull the lens of the light, when I heard a loud noise and the work platform
fell forward and threw me out. The next thing I remember I was on the ground, my arms and legs hurt like crazy, and the first aid
guy was there. They packaged me up put me in the ambulance and took me to the hospital. I think they did a really good job.

OSO: What type of education and training did you receive in the operation of the lift unit?
TL: The company sent me out to a training course in June so I could train the other guys in the use of the new lift. This is a new
boom-type lift. We had an old scissor-type lift before.
OSO: Do you recall who provided the training?
TL: Yeah, it was the Big Boom Lift Company.
OSO: Can you tell me what the training covered?
TL: It was a good course, it was a full day. We spent about 4 hours in the classroom going over the operation and safety
devices that are on the lift. The balance of the day, 4 hours, we went out into their yard for some hands-on operation. We had
to show that we could operate the equipment, identify the components, and went over the maintenance of the unit.
OSO: Do you recall if the course identified any personal protective equipment that had to be used or worn when operating the lift?
TL: Oh yeah, we had to wear hard hats and safety boots out in the yard.
OSO: Do you recall if the use of fall protection and the anchor points for the lanyard were discussed in the course?
TL: I don’t remember, they went over a bunch of safety stuff. They may have discussed fall protection. But we didn’t wear fall
protection in the old scissor lift.
OSO: Were you wearing a full body harness and lanyard at the time of the accident on Sept 6, 2017?
TL: Yeah I always wear my fall protection. I was going to be changing lights all over the mill that day, so I was bound to need it
somewhere. My boss is a real stickler for safety, and she’s always on our case in the crew meetings to use our fall protection gear,
and lock out – that sort of stuff.
OSO: You were not using your fall protection equipment at the time of the accident. That is, your lanyard was not attached to
an anchor point at the time of the accident?
TL: No, I was just getting the work platform into position to change the light, it was flat ground, and we never had to be tied off in
the old scissor lift unless we wanted to.
OSO: Do you know where to anchor your lanyard to in the new Big Boom elevated lift work platform?
TL: Yeah, there’s a ring right under the operating controls.
OSO: The elevated lift is new and has approximately 60 hours on the unit. You have been the primary user of the unit since it
arrived on site?
TL: Yeah, I’ve trained a couple of the guys up on the use of the machine, but I’ve put the bulk of the hours on.
OSO: Do you recall any problems with the machine since you have operated it?
TL: Yeah every once in a while the platform would make a funny noise. Once you moved the platform into level position you’d hear
a dull bang and the platform would shift slightly. I just thought it was tight, since the machine was pretty new, and that it would
wear in.
OSO: Did you mark anything down in the log book?
TL: No, as I said I thought it was just new and would wear in after a few hours. It didn’t do it all the time, just every once in a while.
OSO: Is there anything you’d like to add to this statement?
TL: No, that’s about all I can think today, my head is still a little fuzzy.
 ABC Company
ACCIDENT / INCIDENT
INVESTIGATION REPORT

Injured Worker: Tony Lee Accident Location: Mill Yard

Worker Job Title: Accident Occurrence Date: Time: Shift: Days

Electrician Sept 6/2017 10:30 am

Reported date: Sept 6/2017 Date recorded in First Aid Record Book: Sept 6/2017

What was the worker doing when this accident occurred?

Tony Lee an electrician was in the process of using the new big boom lift to change the lights in the mill yard,
when the man basket cylinder failed causing the work platform to fall forward, throwing the worker
approximately 25 ft to the ground.

Why did this accident/incident occur (primary cause)?

The man basket cylinder on the big boom lift failed causing the work platform to fall forward throwing the
worker out of the work platform. The manufacturer of the lift is conducting its own investigation to determine the
nature of the failure, report to follow.

What other factors contributed to this accident?

− Manufacturing or assembly defect from the manufacturer
− Worker failed to conduct pre-use inspection

What corrective action is necessary to prevent a future accident of this type?

The Big Boom Lift Company and High Lift Supply Company, the supplier of the lift, are currently investigating
the cause of the accident. New basket cylinder ordered and will be installed on the lift. The new cylinder will be
checked by the manufacturer prior to installation. Information on the nature of the failure will be passed on to
the maintenance crews.

What corrective action was taken? Big Boom Lift Co. replaced cylinder
Date of corrective action: New cylinder installed Sept 10/2017
Crew Talk: Yes: X No: Topic: Review accident investigation from manufacturer

Injury Muscle X Broken X Puncture: Cut: X Respiratory:

Type strain: limb:
What body part? Arms, shoulders, legs
Investigated by: Ellen Proto
Safety Committee Review Date: Sept 24/2017 Recommendations: New cylinder installed Sept 10/2017
Management Review by: Joe Bing, Operations Manager
 ABC Company
Crew Meeting Notes

Crew Meeting: Maintenance

March 17 2017

Attendance: Walter on vacation

Discussed lockout in light of incident to Doug MacArthur on the milling machine

Discussed accidents to date. No LTAs to date.

Discussed WHMIS and the products used in the shop.

Kate Campbell will be switching shifts with Zac Applegate for the next two weeks.

Crew Meeting: Maintenance

April 24/17

Attendance: All

Reviewed accidents. No lost times to date.

Jana Dhaliwal received his Journeyman Ticket for Millwright – congratulations Jana.

Discussed the requirements of lockout and the use of fall protection.

Andy Dogwood indicated that the stairs to the sawmill maintenance shop are in poor condition. Scheduled
repair.

Crew Meeting: Maintenance

May 15 2017

Attendance:

Reviewed accident on maintenance stairs. Andy Dogwood slipped on broken stair tread. Stair tread has been replaced.

Discussed safe use of ladders, showed WorkSafe video. Discussed lockout and fall protection.
Crew Meeting: Maintenance
June 14 2017

Attendance: Evan, Kate, and Len missing due to vacation

Talked about accidents to date.

Talked about cleanup in the millwright and electrical shops. Keeping stairways clear of articles is important.

Discussed the process for reporting hazards, and reporting to first aid.

One-on-Ones will be conducted over the next two months with your immediate supervisor.

As we are heading into the summer holiday extra care should be taken.

Crew Meeting: Maintenance

July 25 2017

Attendance: Evan, Kate, Tim, Zac and Sandra on vacation

Discussed accidents to date. No LTAs to date.

Reviewed procedures for removing surplus materials from the mill

Talked about the condition of personal tools.

One-on-Ones continuing.

Crew Meeting: Maintenance

Aug 17/2017

Attendance:

Reviewed accidents. No LTAs to date

One-on-Ones Complete.

Talked about the importance of lockout.

Production complaining of the number of lights in the mill yard that are not working, Will start the annual PM on the
yard lighting next month.

Discussed the build-up of material in the stairways and walkways.

 ABC Company
Extract from
Job Safety Analysis for Electrician

ELECTRICIAN JSA (Job Safety Analysis) 01/08/17

FALL PROTECTION

All workers are required to use fall protection when working 10ft or more above the work surface or when
work at a lesser height involves an unusual risk.

When guardrails are not in place to protect the worker, the worker will use a full body harness, lanyard and
anchors to secure themselves in a fall restraint system or a fall arrest system.

All maintenance workers have been supplied with a full body harness, rope lanyard, two cable anchors
and cable lanyard with a shock absorber. The warehouse stocks extra harnesses, lanyards and anchors
for additional needs or infrequent users.

All workers are responsible for inspection and maintenance of their fall protection equipment. Workers are
responsible to maintain this equipment in good working order and to remove from service any defective
equipment.
JOB: ELECTRICIAN

I have read and reviewed the JSA for the job of electrician. I fully
understand and agree with the written procedures outlined in this JSA.

This JSA for the job of Electrician was reviewed on the following date with my supervisor and I understand that
if at any time I am unsure of the proper procedure to follow, I am to ask my supervisor.

Date:

Supervisor Worker
ELECTRICIAN JSA (Job Safety Analysis) Page 112
Work Procedures 07/26/2015

AERIAL WORK PLATFORM

Only workers authorized and trained may operate the aerial work platform.

The aerial work platform must be operated in accordance to the manufacturer’s manual.

Operators of the aerial work platform will perform an inspection before use to determine if there are any
conditions that may endanger a worker. A record of the inspection must be kept, and deficiencies must be
remedied before the machine is used.

Operators are not to exceed the maximum rated capacity of the machine to lift equipment or tools.
 Big Boom Lift Co.

THIS CERTIFICATE IS PRESENTED TO:

TONY LEE

FOR SUCCESSFULLY COMPLETING THE

TRAIN THE TRAINER COURSE
ON THE
BIG BOOM LIFT

THEREBY BEING QUALIFIED TO PROVIDE

TRAINING IN THE OPERATION OF THE
BIG BOOM PERSONNEL LIFT

Issued: June 29, 2017

Certificate # H46332-A
 ABC Company
Boom Lift Log Book Entries