Date of incident: October 2020
Notice of incident number: 2020181280022
Employers: Heating system installation or repair company; vegetable greenhouse

Incident summary
Two workers were removing a condenser, which was at the end of its service life, from a boiler at a greenhouse facility. The condenser, which weighed approximately 1600 kg, needed to be lowered so it could be removed. It was supported by four adjustable legs. Each leg had three fixing plates, secured by two bolts per fixing plate, to prevent the leg from retracting. To lower the condenser, a jack was placed at the centre of one side of the condenser and the condenser was raised slightly so that there was no weight on the two legs on that side. The workers loosened the bolts securing the fixing plates on those two legs, which were then retracted about 7.5 cm. The bolts were tightened and the condenser was lowered so that the legs were resting on the ground. This process was to be repeated alternately on the right and left sides of the condenser until the condenser was resting on wheels that were to be placed underneath it. During the process, the condenser tipped over, crushing one of the workers against a wall. The worker sustained fatal injuries.

Investigation conclusions

Cause

• Bolts holding condenser legs were inadequately secured. Not all of the bolts securing the condenser legs were tightened. The bolts that were tightened were not sufficient to hold the legs in place. The weight of the condenser caused two of the legs to retract unexpectedly, destabilizing the condenser. The condenser tipped over and pinned the worker against a wall.

Contributing factors

• Inadequate hazard identification. A hazard assessment was not done, so the hazard posed by the potential for the condenser to become unstable was not identified. As a result, the workers did not secure the condenser to prevent injury in case it became unstable.
• Lack of safe work procedures. The workers followed, in reverse order, a procedure in the condenser manual for installing a new condenser in an area with limited space. The procedure was not specific to removal of a condenser at the end of its service life. The procedure in the manual also did not contain steps to ensure the stability of the condenser or details on how much torque was required to ensure that the bolts were tight enough to support the weight of the condenser. The employer did not create its own work procedures to ensure that the necessary steps were taken to perform the work safely.
• Inadequate training and experience. The workers had little direct experience removing condensers from greenhouse heating systems. The worker who was injured had not been provided with a safety orientation or any training on how to perform the work. The employer failed to provide its workers with the information, instruction, and training necessary to perform the work safely.
• Inadequate supervision. The employer failed to provide adequate supervision to ensure that workers tightened the bolts on the condenser legs correctly and did not stand between the condenser and the wall while the work was being performed. The employer failed to provide its workers with supervision to ensure their safety.

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