boi fatality lessons learned 23 sep 2011
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US Army Corps of Engineers
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Board of Investigation (BOI) ReportContractor Fatality at ANP Site
23 September 2011
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BOI Members (Voting Members)
Edwin Cuebas (President)
Charles Comeau (Member) Edwin Perdue (Member)
BOI Advisor (Non-voting members)
Patrick Freedman Technical
Board of Investigation (BOI) ReportContractor Fatality ANP Site
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Board of Investigation (BOI) ReportContractor Fatality ANP Site
Accident Information:
Date: 23 September 2011
Location:XXXXXXXXX
Prime Contractor:XXXXXXXXX
Result: Worker killed while operating a concrete mixer Background:
A concrete mixer operator was cleaning our his concrete mixer inpreparation for lunch
A worker near the mixer heard a noise and turned to find the
mixer operator lying on the ground next to the concrete mixerwith injuries to back
Injured operator was transported to the District medical clinicwhere he later expired from his injuries
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Project Site Layout
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In the photo below, a worker demonstrates the position in which the injuredoperator was found relative the concrete mixer and the mixers loading chute.
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Board of Investigation (BOI) ReportContractor Fatality ANP Site
Direct Cause: The concrete mixers loading bin lowered rapidly striking thevictim and knocking him to the ground.
Indirect Causes:
Lack of an effective safety program to include the lack of training on the
proper operation of equipment such as the concrete mixer.
Contributing Factors:
Conducting concrete mixing operations with only one person created anenvironment more prone to accidents due to the lack of a buddy system.
The operator became complacent due to the lack follow up safetymeetings to remind the operator of the potential hazards while operatingthe equipment.
Worksite was 65 miles from the nearest medical center.
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Board of Investigation (BOI) ReportContractor Fatality ANP Site
Recommendations: Set up a formal training program for personnel operating and working
around this type of concrete mixer. The program should as a minimumcover proper startup, operation, and shutdown of the concrete mixer as wellas the potential hazards associated with the equipment.
Develop a proper AHA for this activity and ensure that three phase
inspections are properly conducted for the activity.
Always have two personnel present during operation of the concrete mixer.
USACE shall ensure Contractor is implementing an acceptable AccidentPrevention Plan & is submitted for review & acceptance
USACE shall ensure the job site is in compliance with the Safety & Health
Requirements Manual (EM 385-1-1)
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Board of Investigation (BOI) ReportContractor Fatality ANP Site
Recommendations (cont.): USACE shall ensure the job site is in compliance with the Safety &
Health Requirements Manual (EM 385-1-1)
USACE shall periodically attend Contractors weekly toolboxmeetings to ensure safety standards are being implemented
properly USACE shall ensure all safety requirements are being maintained
by the Contractor based on EM 385-1-1
USACE shall audit the Contractors safety training records
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Board of Investigation (BOI) ReportContractor Fatality ANP Site
Accident Prevention Items: Contractor shall address all recommendations in their Accident
Prevention Plan (APP) and submitted for review and acceptanceby date here
USACE Safety Officer shall track APP progress to assure
acceptance is done by date here USACE Project Engineer shall audit the Contractors employee
training documents on date here
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Board of Investigation (BOI) ReportContractor Fatality ANP Site
The Board thanks the following for their supportduring the investigation:
Feyzabad Resident Office
Mazar-e-Sharif Area Office
Office of Counsel Safety Office
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Board of Investigation (BOI) ReportContractor Fatality ANP Site
Questions?
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