Case Summary
ESi was hired to assist in a case involving an employee of a third-party contractor who got injured. During maintenance, which included inspection of welds at the front of an autoclave, the worker was pushed into the autoclave when a train containing material unexpectedly energized.
Situation
A third-party contractor (vendor) was hired to conduct a routine maintenance and inspection of the welds at the entrance of an autoclave of a manufacturer of siding material (owner). The autoclave is used to cure the siding material at an elevated temperature and pressure. The owner opened the autoclave overnight to relieve the pressure and let the autoclave cool down, prior to the inspection of the welds. The owner utilized a rail system to move long stacks of siding material into and out of the autoclaves with a front loader. The employee of the vendor was kneeling at the entrance of the autoclave conducting their maintenance task below the line of sight of the driver of the front loader and was unexpectedly pushed into the autoclave by the rail cars stacked with product.
ESi was retained to investigate this incident, and the applicability of standards, such as, the control of hazardous energy (lockout/tagout), the application of OSHA (Occupational Safety and Health Administration) standards regarding permit required confined space and powered industrial trucks.
Analysis
The owner was alleged to have violated the OSHA requirements pertaining to powered industrial trucks, and permit required confined spaces.
Powered Industrial Trucks
It was alleged by another expert that a powered industrial truck was used to move the siding material into and out of the autoclave. Use of powered industrial trucks in the workplace is regulated by 29 CFR 1910.178. However, the train of siding material was moved by an earth moving front loader and not by a powered industrial truck. OSHA explicitly stated in multiple standards interpretations saying earth moving vehicles, such as a front loader, are not regulated by the powered industrial truck regulations. OSHA said it is the design intent of the vehicle by the manufacturer and not the actual use that defines if the vehicle falls within OSHA’s powered industrial truck regulations. Therefore, as the front loader was intended by the manufacturer to be earth moving equipment, the powered industrial truck requirements did not apply to this case.
Permit Required Confined Space
It was alleged by another expert that the owner violated Confined Space regulations by not requiring the vendor to get a permit when performing his maintenance task. A permit required confined space is regulated by 29 CFR 1910.146. OSHA defined a confined space as a space that:
As such, the autoclave was considered a confined space as it met these criteria.
OSHA further defined a confined space that required a permit needed to meet one or more of the following characteristics:
The owner opened the autoclave cover, depressurized the system, and let the system cool down prior to the inspection of the welds, and in accordance with OSHA requirements, conducted lockout/tagout with the injured employee for those systems to mitigate the potential hazardous atmosphere of the autoclave and on the hydraulics that would have potentially closed the autoclave door. Published interpretations written by OSHA said if you eliminated the hazards required for the permit-required confined space, the space could be reclassified as a confined space that did not require a permit to enter.1 By conducting lockout/tagout of the autoclave systems, the autoclave no longer had the potential to contain a hazardous atmosphere, did not contain any material that had the potential to engulf the entrant, did not have an internal configuration such that the entrant could be trapped or asphyxiated by inwardly converging walls, and there were no other recognized serious safety or health hazards within the autoclave. Therefore, had the front loader been locked out/tagged out, then the confined space would not have required a permit to enter and work. Permit required confined spaces require the implementation of additional risk mitigation measures while workers are working in that confined space that was not required for the maintenance task being performed.
Control of Hazardous Energy (Lockout/Tagout)
The control of hazardous energy is regulated by 29 CFR 1910.147. The control of hazardous energy is the relieving, disconnecting, restraining or otherwise rendering any hazardous energy (e.g., electrical, mechanical, thermal, etc.) safe, and securing it from being reenergized during a cleaning or maintenance activity. The owner and the vendor had conducted lockout/tagout of other hazardous energies of the autoclave, such as preventing the cover from falling, thermal hazards, etc., but did not conduct lockout/tagout on the potential hazardous energy of the front wheel loader being energized and moved. This was because the vendor had broken with procedure and exposed themselves to the hazard. The front loader was supposed to move the material into the autoclave prior to starting his maintenance task, thus rendering the hazardous energy safe. When multiple employers are involved in lockout/tagout, all parties have a shared responsibility to inform each other of their control of hazardous energy programs.2 Therefore, both the third-party contractor (the injured party’s employer) and the owner had responsibilities for the control of hazardous energy.
The incident is an example of the shared failure by the parties to conduct lockout/tagout of the front loader that was used to place the rail cars full of product into the autoclave and the injured party breaking with standard operating procedure.
Results
By conducting further research into the OSHA standards and their respective interpretations, ESi explained OSHA’s requirements for powered industrial trucks, permit required confined spaces, and lockout/tagout. The results of ESi’s investigation assisted the client in explaining the incident as the shared failure by the parties to conduct lockout/tagout of the front loader, and not issues related to powered industrial trucks and permit required confined spaces as alleged.
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