2012 fatality report: worker crushed by air handling unit · 6.4 air handling unit components five...

1 Alberta Human Services, Occupational Health and Safety

WORKER CRUSHED BY AIR HANDLING

UNIT

Type of Incident: Fatality

Date of Incident: November 14, 2012

File: F-488087


TABLE OF CONTENTS

SECTION TITLE PAGE NUMBER

1.0 DATE AND TIME OF INCIDENT 3

2.0 NAME & ADDRESS OF PRINCIPAL PARTIES 3

2.1 Owner 3

2.2 Prime Contractor 3

2.3 Contractor(s) 3

2.4 Employer(s) 3

2.5 Supplier(s) 3

2.6 Workers(s) 3

2.7 Others 4

3.0 DESCRIPTION OF PRINCIPAL PARTIES 4

3.1 Owner(s) 4

3.2 Prime Contractor(s) 4

3.3 Contractor(s) 4

3.4 Employer(s) 4

3.5 Worker(s) 4

4.0 LOCATION OF INCIDENT 4

5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5

5.1 Equipment and Material 5

5.2 Observations 5

6.0 NARRATIVE DESCRIPTION OF INCIDENT 6

7.0 ANALYSIS 7

7.1 Direct Cause 7

7.2 Contributing Factors 7

8.0 FOLLOW-UP/ ACTION TAKEN 7

8.1 Human Services, Occupational Health and Safety 7

8.2 Industry 8

8.3 Additional Measures 9

9.0 SIGNATURES 10

10.0 ATTACHMENTS 10

File: F-488087


SECTION 1.0 DATE AND TIME OF INCIDENT

1.1 November 14, 2012 at approximately 1:30 p.m.

SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES

2.1 Owner(s)

2.1.1 University of Lethbridge

4401 University Drive West

Lethbridge, Alberta

T1K 3M4

2.2 Prime Contractor

2.2.1 Stuart Olson Dominion Construction Ltd.

6th

Floor, 4838 Richard Road S.W.

Calgary, Alberta

T3E 6L1

2.3 Employer

2.3.1 Zero Gravity Cranes & Rigging Inc.

332 – 36 Street North

Lethbridge, Alberta

T1H 3Z7

2.4 Contractor(s)

2.4.1 K.B. Heating & Air Conditioning Ltd.

3020 – 16 Avenue North

Lethbridge, Alberta

T1H 5E9

2.5 Supplier(s)

2.5.1 Not applicable.

2.6 Worker(s)

2.6.1 The Foreman (***********)

(Names and personal details were removed before distribution of this report.)

File: F-488087


2.7 Others

2.7.1 Constable (**** *******)

Lethbridge Regional Police Service

135 – 1 Avenue South

Lethbridge, Alberta

T1J 0A1

SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES

3.1 The University of Lethbridge is a publicly funded academic and research university

located in Lethbridge, Alberta. It has other campuses in Calgary and Edmonton. The

University of Lethbridge hired Stuart Olson Dominion Construction Ltd. to oversee

construction of Phase 3 of its 259 bed student residences at Aperture Park located at

the southwest corner of the University property.

3.2 Stuart Olson Dominion Construction Ltd. (Stuart Olson) is a progressive builder and

construction management firm with offices in Calgary, Edmonton and Saskatoon.

Stuart Olson is the prime contractor for construction of the student residences. Stuart

Olson is responsible for selecting and hiring sub-trade contractors for various phases

of construction.

3.3 K.B. Heating & Air Conditioning Ltd. (K.B.) is the heating, ventilation and air

conditioning (HVAC) contractor hired by Stuart Olson to supply and install HVAC

equipment.

3.4 Zero Gravity Cranes & Rigging Inc. (Zero Gravity) is a locally owned business

focussed on industrial hoisting and rigging. Zero Gravity employs approximately 20

workers with backgrounds in welding, ironworking, rigging and crane operations.

Zero Gravity was hired by K.B. Heating & Air Conditioning Ltd. to install air

handling unit components and boilers at the student residences.

3.5 The Foreman (***********) was employed by Zero Gravity to oversee a crew

responsible for installation of various types of equipment. The Foreman

(***********) was a journeyman welder and third year apprentice ironworker. The

Foreman (***********) had been employed by Zero Gravity for approximately two

years and had more than ten years of related work experience.

File: F-488087


SECTION 4.0 LOCATION OF INCIDENT

4.1 The incident occurred in the mechanical room located in the southeast corner of the

basement of the north wing of the Phase 3 Aperture Park student residences at the

University of Lethbridge (Refer to Attachment A – Map and Attachment B –

Photographs 1, 2 and 3).

SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS

5.1 Equipment and Material

5.1.1 A McQuay Energy Recovery Wheel, Model ECW 846 (Serial Number

*************) was component 4 of 6 components of an air handling unit being

installed on a concrete pad (pad). Component 4 measured approximately 3.6 meters

long x 0.7 meters wide x 3.0 meters high and weighed 1,242.5 kilograms (Refer to

Attachment B – Photographs 3 to 6 and Attachment C - Drawing).

5.1.2 The pad measured approximately 9.1 meters long x 4.4 meters wide x 0.1 meters high

(Refer to Attachment B – Photograph 5 and 6 and Attachment C – Drawing).

5.1.3 Four employer-fabricated, steel, roller carts (carts) measuring approximately 0.6

meters long x 0.5 meters wide x 0.2 meters high and having a load capacity of 1.36

tonnes were used to move component 4 into the building and into position on the pad

(Refer to Attachment B – Photograph 7).

5.1.4 Two Simplex, Model A 1022, 10-ton (9.07 tonne), mechanical, ratchet jacks (jacks),

stamped 001 and 005 were being used to position component 4 (Refer to Attachment

B – Photograph 8). The jacks were positioned on the east and west corners at the

north end of component 4 (Refer to Attachment B – Photograph 6 and Attachment C -

Drawing).

5.1.5 Plywood squares measuring approximately 0.3 meters long x 0.3 meters wide x 0.02

meters thick were used to support the middle of component 4 while it was being

positioned on the pad (Refer to Attachment B – Photograph 6 and Attachment C -

Drawing).

5.1.6 A single timber measuring approximately 1.2 meters long x 0.1 meters wide x 0.2

meters high was used to support the south end of component 4 during positioning

(Refer to Attachment B – Photograph 6 and Attachment C - Drawing).

5.2 Observations

5.2.1 Component four was narrower than components five and six.

File: F-488087


SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT

6.1 The Employer (************), Worker 1 (************) and Worker 2

(***********) arrived at the Zero Gravity yard and loaded air handling unit

components onto trailers and transported them to the work site.

6.2 Upon arrival at the work site, the Employer (************) spoke to the Stuart

Olsen crane riggers and the Site Superintendent (************). They discussed the

plan for unloading and transferring the air handling unit components into the entrance

of the mechanical room located in the southeast corner of the basement of the north

wing of the student residences.

6.3 The Foreman (***********) arrived at the work site at approximately 9:00 a.m. and

met with the Employer (************), Worker 1 (************), Worker 2

(***********) and Worker 3 (**************) as well as workers from K.B. The

Foreman (***********) conducted a toolbox meeting which included a hazard

assessment for installation of the air handling unit components.

6.4 Air handling unit components five and six were moved into position and permanently

installed on the pad between 9:30 and 11:30 a.m. Due to windy conditions, Zero

Gravity workers then took a lunch break.

6.5 After the lunch break, component four was craned into the door opening, rolled into

the mechanical room on carts and moved onto the pad. This procedure called “jack

and roll” is commonly used by Zero Gravity to install equipment of various shapes

and sizes where other methods such as overhead craning are not feasible.

6.6 At approximately 1:15 p.m., the Foreman (***********) began coordinating the

installation of air handling unit component 4 on the pad with help from Worker 1

(************) and Worker 3 (**************).

6.7 Component four was blocked at the south end with a single timber. The carts were

removed by jacking up component four and installing plywood squares at the center

of the component.

6.8 Worker 1 (************), Worker 3 (**************) and the Foreman

(***********) began final positioning of component 4. Worker 1 (************)

and Worker 3 (**************) raised the jacks at the north end simultaneously

while the Foreman (***********) removed plywood squares at the center. The jacks

were then lowered simultaneously onto the next squares. This process would have

been repeated until one end of component 4 was resting on the pad.

6.9 During final positioning of component 4, jack 001 supporting the northeast corner of

component 4 suddenly dropped. Worker 3 (***************), who was positioned

File: F-488087


at the northeast corner of the component, said he heard a clink, yelled out a warning

and jumped clear of the falling component. Worker 1 (************) located at the

northwest corner of the component moved off to the side.

6.10 The Foreman (***********) scrambled east from his position at the center of

component four but was unable to clear the falling component. Component four

landed on him, trapping him underneath.

6.11 Worker 1 (************) and Worker 3 (**************), with the assistance of

K.B. workers, lifted component 4 and extracted the Foreman (***********) from

underneath.

6.12 Worker 4 (**********) phoned 911 requesting Emergency Medical Services (EMS).

Worker 6 (*************) came from his work location and initiated first aid. Zero

Gravity workers assisted until EMS personnel arrived.

6.13 EMS took over treating the Foreman (***********). Lethbridge Regional Police

Service (LRPS) arrived shortly thereafter and began an investigation.

6.14 The Foreman (***********) was pronounced deceased at the work site.

SECTION 7.0 ANALYSIS

7.1 Direct Cause

7.1.1 The Foreman (***********) received fatal injuries when component four of an air

handling unit fell on him.

7.2 Contributing Factors

7.2.1 Simplex jack 001 that was supporting the northeast corner of component 4 suddenly

dropped. Engineering tests conducted on Simplex jack 001 showed that it had the

potential for failure (Refer to Attachment D – 10 Ton Jack Mechanical Assessment).

7.2.2 Component four had not been blocked adjacent to the two jacks at the north end of

component four.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN

8.1 Human Services, Occupational Health and Safety

8.1.1 On November 14, 2012, Occupational Health and Safety (OHS) received an incident

notification, responded to the scene and commenced an incident investigation.

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File: F-488087


8.1.2 OHS issued the following orders to Zero Gravity:

Stop work order for positioning of air handling unit components until controls for

potential tip over hazards are developed and workers have been trained in those

control measures.

Stop use of jacks until the employer ensures that they are maintained and

functioning in accordance with the manufacturer’s specifications or specifications

certified by a professional engineer.

8.1.3 OHS issued a Demand to Zero Gravity for copies of information related to the

incident.

8.1.4 OHS also issued the following orders to Stuart Olson:

Stop work order for positioning of air handling unit components as discussed with

Stuart Olson and K.B. representatives until remedial measures are put in place to

prevent a recurrence.

Complete an investigation outlining the circumstances of the accident and the

corrective action undertaken to prevent a recurrence and provide a copy of the

report to OHS.

8.1.5 OHS seized the two Simplex jacks involved in the incident and contracted a third

party mechanical engineering firm to inspect and function test the jacks.

8.2 Industry

8.2.1 Zero Gravity reviewed and amended procedures for the installation of air handling

unit components and future installation of boiler units. A meeting with Stuart Olson,

K.B., Zero Gravity, University of Lethbridge and OHS representatives was held to

review the procedures.

8.2.2 Zero Gravity purchased two new Simplex mechanical jacks and removed all other

Simplex mechanical jacks from service.

8.2.3 Zero Gravity provided all documents demanded along with a copy of their health and

safety program and Certificate of Recognition.

8.2.4 Zero Gravity complied with all orders issued by OHS.

8.2.5 Stuart Olson completed an incident investigation and provided a copy of the report to

OHS for review.

File: F-488087


8.3 Additional Measures

8.3.1 Not applicable.

File: F-488087


SECTION 9.0 SIGNATURES

Original report signed___________ _____________________

(*********), Lead Investigator Date


(**************), Reviewer Date


(************), Director Investigation and Mining Date

SECTION 10.0 ATTACHMENTS:

Attachment A Map.

Attachment B Photographs.

Attachment C Drawing.

Attachment D 10 Ton Jack Mechanical Assessment.

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ZERO GRAVITY CRANES AND RIGGING INC. File: F-488087

ATTACHMENT A

MAP

Red arrow shows the location where the incident occurred at the University of Lethbridge,

Phase 3 Aperture Park Student Residences in Lethbridge, Alberta.

Alberta Human Services, Occupational Health and Safety

ZERO GRAVITY CRANES & RIGGING INC. FILE: F-488087

ATTACHMENT B

PHOTOGRAPH 1 of 8

Photograph 1 - Picture shows the location where the incident occurred – Phase 3 Aperture Park

student residences at the University of Lethbridge. Red arrow designates the north

wing of the residences.



ATTACHMENT B

PHOTOGRAPH 2 of 8

Photograph 2 - Green arrow shows the doorway of the mechanical room in the basement that

component four was craned into prior to being positioned on the pad.



ATTACHMENT B

PHOTOGRAPH 3 of 8

Photograph 3 - Shows the mechanical room in the basement of the student residences where the

incident occurred. Red arrow shows the doorway that components four, five and six

were brought through. Green arrow shows components five and six which were

installed prior to the incident. Blue arrow shows component four in its approximate

resting position after the incident.



ATTACHMENT B

PHOTOGRAPH 4 of 8

Photograph 4 – Shows a schematic layout of components one to six of the air handling unit. The

highlighted component four was involved in the incident.



ATTACHMENT B

PHOTOGRAPH 5 of 8

Photograph 5 - Shows component four being recovered after the incident and prior to being lifted into

position on the pad. Blue arrow shows the pad on which all components were to be

placed.



ATTACHMENT B

PHOTOGRAPH 6 of 8

Photograph 6 – Shows the approximate position of component four after it fell.

1. Shows the single timber used to support the south end of component four during

positioning.

2. Shows the pad on which all components were to be placed.

3. Shows plywood squares used to support the middle of component four while it

was being positioned on the pad.

4. Shows the approximate contact position of Simplex jack 001 prior to the incident.

5. Shows the approximate contact position of Simplex jack 005 prior to the incident.


1

2

3

5

4


ATTACHMENT B

PHOTOGRAPH 7 of 8

Photograph 7 – Shows two of the four employer-fabricated carts used to move air handling unit

components into the mechanical room located in the basement and into position on the

pad.



ATTACHMENT B

PHOTOGRAPH 8 of 8

Photograph 8 – Shows the Simplex, Model A 1022, 10-ton, mechanical, ratchet jacks involved in the

incident.


ZERO GRAVITY CRANES AND RIGGING INC. File: F-488087

ATTACHMENT C

DRAWING

Drawing shows the concrete pad with component four of the

air handling unit in position.

Blue arrows show locations of Simplex jacks

Red arrows show locations of plywood squares in the middle of

component four.

Green arrow shows single timber supporting the south end of

component four.

Concrete Pad 4

South Exterior Wall Doorway

2012 fatality report: worker crushed by air handling unit · 6.4 air handling unit components five...

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