Date of incident: June 2020
Notice of incident number: 2020116110013
Employer: Building demolition firm

Incident summary
At a rock and gravel supply pit, two workers were carrying out maintenance on an excavator’s hydraulic pulverizer attachment while the machine was running. One worker entered the excavator’s cab and inadvertently brushed a control lever, which caused the machine to swing unexpectedly. The other worker was struck by the hydraulic attachment head and pinned against a nearby service truck. He sustained serious injuries.

Investigation conclusions

Cause

• Failure to follow employer’s safe work procedures and manufacturers’ instructions. The pilot control shut-off lever had not been raised to the LOCK position, which would have disabled the hydraulic controls to the machine. Nor had the machine been shut off and the controls locked out. The machine was left running and the hydraulic attachment’s head was rotated while a worker was within the swing radius. Neither the employer’s safe work procedures nor the manufacturers’ instructions, including the generic hydraulic excavator safety manual, were followed when maintenance was carried out on the hydraulic attachment connected to the excavator. This led to the excavator swinging to the right, pinning a worker.

Contributing factors

• Inadequate supervision. The employer did not ensure workers followed its safe work procedures and obtained manufacturers’ instructions for the excavator or the hydraulic attachment prior to carrying out maintenance on the hydraulic attachment. This led to the attachment being raised above the ground when it should not have been. The excavator was left running and not locked out when it should have been turned off and locked out. The service truck was parked within the swing radius of the excavator and a worker was within the swing radius when the attachment head was rotated.
• Inadequate information and instruction. The employer supplied workers with a copy of the generic hydraulic excavator safety manual but did not ensure workers read it. The employer did not provide workers with a copy of the excavator operator’s manual from the manufacturer and did not have a copy of instructions for the hydraulic attachment readily available. The employer did not ensure that the workers understood or applied the equipment procedures when it came to working on faulty tools and equipment.

Request the full report