Fan broke apart and fatally injured worker
Date of incident: November 2020
Notice of incident number: 2020184470084
Employer: Concrete manufacturer
Incident summary
At a cement production plant, a worker was near the front of a large induction fan. Cement processing was underway and the fan was running. An impeller (rotor) in the fan broke apart and debris from the fan, including its blades and other components, was propelled through the fan housing and across the yard, some of it landing as much as 29 m (94 ft.) away. The worker was struck by the debris and sustained fatal injuries.
Investigation conclusions
Cause
- Improperly repaired fan broke apart and debris struck worker. The fan underwent a catastrophic failure in which the blades of its impeller broke apart. The fan’s impeller had been removed from service years earlier as a result of wear, but had been refurbished and returned to service about five months before the incident.
Contributing factors
- Failure to provide adequate information, instruction, and training. The employer tasked a worker with developing and overseeing the refurbishment process for the impeller. However, the employer did not provide the information, instruction, and training required to execute the refurbishment in a manner that eliminated or lessened the risks to workers’ safety from returning the impeller to operation.
- No professional engineering involvement. The employer had access to engineering services internally and had enlisted the assistance of outside engineering services for previous repairs made to the fan. However, for undetermined reasons these resources were not enlisted during the process of refurbishing the impeller in 2020. The maintenance manual for the fan strongly recommended that its manufacturer be contacted if users were considering repairing the fan. Yet the employer did not ensure that anyone involved in the fan’s repair contacted the manufacturer. Because of the lack of professional engineering input on the project, workers did not recognize that repairing the impeller might not be viable, or that the repairs that were made to it did not in fact restore its structural integrity. Having a professional engineer involved in the project could also have enabled the employer to verify that the repaired impeller and the fan were properly inspected and deemed safe to operate before the fan was put into service.
- Ineffective health and safety program led to inadequate supervision and risk assessment. The employer’s health and safety program was not implemented at the incident site as prescribed in the firm’s health and safety manual. Workers were not given the required support and resources to put the program into effect. Tasks related to the refurbishment of the impeller were assigned and related costs were approved without adequate health and safety oversight. The fan was not properly inspected when the impeller was installed in it before putting the fan back into service. No one identified the hazard of the impeller breaking apart during use, even though the repairs to it were seen as temporary. The risks to workers if this should happen were not assessed, and no controls were put in place to reduce the risks.
2021-04-22 20:42:33