Date of incident: December 2020
Notice of incident number: 2020181300066
Employer: Insulation installer

Incident summary
At a residential apartment building construction site, a young and new worker was standing on a stepladder, inserting spray-on fibreglass insulation into an insulation-blowing machine by hand. With spray-on fibreglass insulation, the fibres can build up (bridge) in certain areas of the machine’s hopper, creating undesirable voids in other areas. To address the bridging and help ensure consistent flow and spray-on application of the insulation, the worker occasionally reached into the hopper with a small stick to break up and push the chunks into the voids. While hand-feeding insulation into the machine, the worker inadvertently dropped his cellphone into the hopper. He instinctively reached forward to catch the cellphone, and his arm became entangled in the machine’s scalping augers. The worker sustained serious injuries.

Investigation conclusions

Cause

• Elevation of worker defeated safeguard. The worker had been instructed to stand on the stepladder so he could address the bridging in the hopper. Use of the stepladder elevated the worker, which defeated the machine’s safeguard and made inadvertent contact with the energized augers possible. Elevating the worker also increased the likelihood of objects being dropped into the machine.
• Inadequate safety management system. The employer was not aware that the use of the stepladder to address the bridging issue defeated the machine’s safeguard. The employer presumed it was safe to use the stepladder and trained the workers to do so. The employer did not anticipate that a worker would reach into the machine while it was operating, although it was foreseeable that objects could fall into the machine and that the machine’s safeguard had been defeated.

Contributing factors

• Design, use, and limitations of machine. Bridging was an unanticipated problem that was caused in the machine when processing spray-on fibreglass. Without this issue, there was no need to elevate the worker. The machine’s manual neither supported nor warned against elevating the worker. After the incident, the machine manufacturer redesigned the machine and eliminated the bridging problem.

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