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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=854">Fatality Incurred while driving Gradall Material Handler on a Narrow Service Road – Tice Electric Company</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>For a copy of the original report, see “Attachments” on Lessons Learned page.
On October 1, 2013, a Tice Electric Company (Tice) employee was killed while driving a Gradall, Model 534D9-45, Material Handler (Gradall) on a remote Forest Service Road in Montana, enroute to a pre- established pickup point. The Gradall left the roadway, rolled down an embankment, and over the employee. The accident was witnessed by others who were following close behind.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>BPA contracted Tice to replace an emergency generator, renovate a building, make minor structural modifications on facility structures, and replace other electrical equipment and fixtures at a remote Patrick Knob Radio Station in Montana. The project included site-specific instructions and technical specifications. BPA approved Tice’s Site-Specific Safety Plan (SSSP) and provided the Notice to Proceed (NTP) on September 9, 2013.
Within Tice’s SSSP it was noted that the last four miles of the access road had reduced clearance where vehicles could not pass without one moving off the road. To ensure safe travel vehicle speeds had to be less than five miles per hour in that area.
Tice started onsite work the week of September 23, 2013; its crew consisted of a Tice Lead Electrician (TLE), Tice Lineman (TL), Tice Material Handler Employee (TMHE), and the Electrical Construction Company Safety Watch (ECSW). To facilitate the removal of the old emergency generator, Tice rented a Gradall. It was equipped with a Roll-Over Protection System (ROPS) and operator safety restraints. On the morning of the incident the TLE, who was certified to operate the Gradall in accordance with company requirements, drove it approximately 11.5 miles up to the radio station via the service road. During the day, the TMHE operated the Gradall several times. There were no abnormal mechanical conditions or problems noted.
In the afternoon, the TLE was tasked with returning the Gradall to the delivery site so the rental agency could pick it up, as the TMHE needed to load additional materials onto a flatbed truck. The TMHE was to follow the Grandell down the road. All workers agreed that at some point the truck would catch up and need to pass the slower moving Grandell. It was decided that the truck would signal the Grandall by honking the horn, and the TLE would move the Grandall over, when it was safe to do so, to allow the truck to pass.
About four miles from the worksite, the TL saw the Gradall leave the road and the TLE attempt to steer it back onto the road. However, the Gradall paused at the edge of the road, leaning to the downside of the hill. Then TLE attempted to exit the Gradall from the uphill side, as it rolled off the road edge and out of sight.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>The following items could have contributed to the event:
Equipment Status: The reason the Gradall left the road, creating an equipment rollover situation, is unknown as there was no evidence of equipment malfunction or failure.
Operator’s Actions: The TLE attempted to exit the Gradall prior to the roll over. This defeated the built-in safety restraint component (seat belts) and the ROPS. Both particularly designed to protect the operator in this type of situation.
Operator’s Qualifications: The TLE had been appropriately trained and certified to operate the Grandall.
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<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Below are the consequences of the above event. They are provided for information and discussion purposes only.
BPA convened a Board to investigate this event. They determined that:
Material handling equipment training for operators is to include detailed explanations of the ROPS including the importance of using the safety restraints, and what to do during a rollover event.
BPA is to evaluate the need to include information in contract packages outlining BPA’s accident reporting and investigating requirements, including BPA’s accident investigation protocols.
Expectations for how to convey SSSP requirements to workers is to be included on its cover page. The site foreman or manager is to ensure each worker is briefed on SSSP contents before starting any work on the site.
Conduct daily and weekly safety briefing, evaluate and determine if documenting these briefings needs to be a standard requirement for contracted projects, and made available for inspection upon request.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>When Jefferson Lab rents material handling equipment, the Material Handling Coordinator inspects it for safety; and the operator’s certifications are review and validated prior to commencement of work.
Roadways and other areas are kept in good repair to avoid the possibility of rollover.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">10/21/2014 9:18:03 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those with current Material Handling Training</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">854</td>
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<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2014-JLAB-854</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
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<td class="label" nowrap>Safety Related:</td>
<td class="dataval">YES</td>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Issued:</td>
<td class="dataval">10/21/2014 9:16:50 AM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">10/21/2014 9:18:03 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
DOECRD
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<td class="label" nowrap>Location:</td>
<td class="dataval">OTHER</td>
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<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
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<td class="label" nowrap>Contact:</td>
<td class="dataval">Brad Bea, Chief Safety Officer, Bonneville Power Administration (BPA)</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Viewings:</td>
<td class="dataval">3 times</td>
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<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3421">M:\wcd\LessonsLearned\Material Handling\DOE - TurnOver.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Material Handling Equipment</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF300: AERIAL WORK PLATFORM</li>
<li>SAF303: SCAFFOLD SAFETY</li>
<li>SAF402-1: CRANE OPERATOR TRAINING</li>
<li>SAF502: FORKLIFT OPERATOR</li>
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<legend>Distribution/Notification</legend>
<ul class="lesson_attribute_listing">
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
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