Summary
At a plywood mill, a loader was carrying a load of peeled logs as it entered a large concrete tunnel called a vat. Peeled logs were being placed in the vat where the logs would be soaked with hot water for softening prior to being peeled into veneer for plywood. The load of logs struck a worker who was just inside the entrance to one of the vats. The worker received fatal crushing injuries.

Conclusions

Findings as to causes

• A loader entered a vat tunnel with a load of peeler logs without the loader operator's knowledge that the vat man was located inside the vat. The vat man was struck by the load of peeled logs.

• The vat man was not visible to the loader operator. The loader operator's visibility was limited, and the vat entrance was dark.
• The loader operator was unaware that the vat man had accessed the vat pad area.
• The access to the vat pad area lacked clearly defined and enforced protocols. The employer had not identified who could access the vat pad or how and when the vat pad area could be accessed.
• A proper risk assessment had not been conducted for the vat man's required duties.
• The written job procedures for the vat man did not clearly identify and emphasize the hazards, particularly the degree of risk associated with fast-moving loaders and pedestrian traffic.
• Previous near misses of equipment and pedestrians on the vat pad had not been properly investigated and no corrective actions had been taken to prevent future incidents.

Link:
Hazard alert