Date of incident: February 2023
Notice of incident number: 2023179460008
Employer: Welding and fabricating company

Incident summary
A worker in a welding fabrication shop was working between a metal press and a shipping container (sea can), likely moving the metal press using a modified gantry crane and chain hoist that was nearby. The metal press tipped over and the worker became trapped between the metal press and the sea can. The worker sustained fatal injuries.

Investigation conclusions

Cause

• Metal press disconnected from chain hoist hook. The incident was unwitnessed, but investigators determined that the worker was likely moving the metal press with the use of the wheeled gantry crane and chain hoist. The metal press became disconnected from the chain hoist hook, and the metal press tilted toward the sea can, trapping the worker.

Contributing factors

• Failure to adhere to manufacturer’s instructions. The employer did not ensure that the metal press was properly secured to the floor, as required by the manufacturer’s operating manual. As a result, the top-heavy metal press was unstable and able to tip over.
• Lack of safety latch on chain hook. The employer did not comply with the Occupational Health and Safety Regulation, which requires a chain hook to have a safety latch. Had the employer ensured that the safety latch was in place, the chain hoist hook most likely would not have disconnected from the metal press.
• Failure to identify hazards and assess risks. The employer did not identify foreseeable hazards and assess risks in the workplace. Had the employer completed a hazard identification and risk assessment before starting work activities, it would likely have realized that working around the unsecured top-heavy metal press posed a high risk of injury.
• Lack of safe work procedures. The employer did not have any safe work procedures for the process of moving the metal press. This allowed an unsafe process to be introduced that increased the risk of injury from the movement of the metal press and resulted in the incident.
• Lack of equipment inspections. The employer did not complete regular equipment inspections. Had the employer conducted regular equipment inspections, it likely would have identified the deficiencies with the gantry crane and the metal press.

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