Date of incident: June 2013
Notice of incident number: 2013163800660
Employer: Sawmill

Incident summary
As part of a cleanup crew at a sawmill, a young worker was removing sawdust and other wood debris from the area assigned to him by his supervisor. The supervisor had directed the young worker to work in areas away from the running machinery and conveyors, and observed the young worker to be following his instructions. The young worker then reminded his supervisor that he needed a waste bucket, and the supervisor left to get one. While walking through the sawmill, the supervisor saw that the chain drive for a waste conveyor was running but that the conveyor belt itself was not moving. He returned to find that the young worker was trapped between a conveyor belt and the metal frame supporting the conveyor tray and idler roller. The conveyor belt was cut to free the young worker, but he died from his injuries.

Investigation conclusions
Cause

• Young worker caught between conveyor belt and metal framework: The young worker, part of a night-shift cleanup crew at a sawmill, was working right next to a moving conveyor belt that was not guarded or locked out. While cleaning the floor using compressed air from a hose and wand attachment, he became entangled in the return belt of a waste conveyor, and was pinned up against the metal frame supporting the conveyor tray and idler roller. He suffered fatal injuries.

• Extended production cycle exposed young workers to unfamiliar hazards: The cleanup crew of young workers usually worked after the mill was shut down, and after production had ended for the night. On this occasion, however, production was planned to extend into the cleanup workers' shift. One of the young workers was assigned to an area he was familiar with and had worked in before, but not under these circumstances, where the hazards of operating equipment and conveyors were present, which would normally have been shut off and locked out.
• Lack of guarding around running conveyor: A perimeter guard, intended to provide guarding for the waste conveyor, was missing its bottom rail at the time of the incident, and was therefore not providing proper protection to workers to keep them away from the hazard while the equipment was operating.
• Waste conveyor not locked out: Together, the supervisor and the young worker had locked out several pieces of equipment in the assigned work area, but did not de-energize or lock out the waste conveyor, which continued to operate. While performing cleanup duties, the young worker was working near the running waste conveyor, which should have been de-energized and locked out.
• Inadequate information, instruction, training, and supervision provided to the young worker: At the time of the incident, there was only one supervisor for 17 young workers on the cleanup crew. Production in some areas of the sawmill was ongoing, which was a new situation for the young worker. While working on his own, the young worker was cleaning in the immediate area around an unguarded running conveyor. He was not provided with adequate information, instruction, training, and supervision to recognize the incomplete guard, or to identify the area beyond the intended guard as a lockout area.

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