California NURSE Project
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SUMMARY : CASE
292-008-01
An asparagus
sledder was loading bunches of asparagus into large bins.
The bins ride on platforms built onto a tractor. As the tractor
moves slowly through the field, the sledder steps off the
platform, scoops up a bundle of asparagus, jumps back on the
platform and puts the asparagus into the bin.
The
field was soft and bumpy, and the platforms and bins were
bouncing around. The sledder jumped onto the platform with
a load of asparagus in his hands. He tried to lean against
a bin to steady himself, but the bin had bounced out of position.
He lost his balance and fell against the rear wheel of the
tractor. The tire tread caught his loose jacket and pulled
him off the platform and down to the ground. The wheel then
ran over his chest. Fortunately, the ground was soft and the
tire pressed the worker into the dirt without crushing his
chest.
How
could this injury have been prevented?
- Wear
tight-fitting clothing when working around moving machinery.
- Think
safety when redesigning equipment. The tractor should have
had a guard rail to protect the worker from the rear wheel,
and the bins should have been anchored to the platforms.
- Work
as a team. The tractor driver might have been able to stop
the tractor when the sledder fell if he was watching his
partner.
- Keep
hands free when working.
BACKGROUND
On March
20, 1992, a local acute care general hospital reported that
an asparagus sledder had been admitted for treatment of a
crushing injury to his chest and possible rib fractures. The
worker had lost his balance and was pulled underneath the
wheel of a tractor. At the time of the injury the worker had
been loading asparagus into transport bins, or "sleds", which
are mounted on platforms next to the rear wheels of the tractor.
The
incident took place in an asparagus field of approximately
500 acres. A nurse from the NURSE Project discussed the incident
with the injured worker on March 25, 1992. NURSE staff reviewed
the emergency medical services run sheets and the hospital
medical records. A Senior Safety Engineer and a nurse from
the NURSE Project discussed the incident and conducted an
on-site investigation with the worker's employer, a farm labor
contractor, on April 6, 1992. Farm labor contractors are used
by some farm owners and operators of large corporate farms
in California to recruit, train and manage workers. This contractor
has a crew of approximately 120 workers specializing in asparagus
picking. The crews work approximately six months on the asparagus
harvest.
The
incident was not reported to or investigated by the California
Occupational Safety and Health Administration (Cal/OSHA).
The farm labor contractor's safety program was reviewed by
the NURSE Project Safety Engineer and was found to address
all seven points required by Title 8 California Code of Regulations
3203 -- Injury and Illness Prevention Program. (As of July
1, 1991 the State of California requires all employers to
have a written seven point injury prevention program: designated
safety person responsible for implementing the program; mode
for ensuring employee compliance; hazard communication; hazard
evaluation through periodic inspections; injury investigation
procedures; intervention process for correcting hazards; and
a health and safety program.)
INCIDENT
On March
13, 1992 at approximately 11:50 a.m. a field worker was loading
asparagus into a bin on a platform attached to a tractor.
The worker lost his balance, was pulled off the platform,
down to the ground, and run over by one of the large rear
wheels of the tractor.
The
asparagus loading operation uses tractors with the seat removed,
and with platforms for holding asparagus bins attached around
the sides and rear. The driver stands on a platform at the
rear of the tractor, where he observes his co-worker and controls
the vehicle. His co- worker, the "sledder", also rides the
platform and steps off to retrieve the bunches of asparagus
which have been cut and stacked on top of the field rows by
the pickers/cutters. The sledder keeps an 18 inch rubber loop
wrapped around both hands and uses it as a sling to pick up
the bundles of asparagus. The sledder places the asparagus
in the large bins which ride on the platforms on the outside
of the tractor wheels, one bin on each side of the tractor.
The bins rest on tracks on the platform, secured at one end.
As the asparagus is laid in the bins a burlap cloth covering
is laid over the stacked asparagus at one foot intervals to
keep the asparagus from moving. When the bins are filled to
the top (approximately 3 feet high) they are covered with
a final burlap cloth which is fastened down. The full bins
are then removed to a waiting truck, and an empty bin is placed
on the sled. The driver and the sledder work as a team and
switch positions throughout the work day.
The
sledder was wearing a loose fitting jacket when the incident
occurred. He ran up to the platform with both hands holding
a load of asparagus in the rubber sling. The rows had been
newly cultivated to remove weeds and make easier access for
the tractor. The platform was soft and unsteady due to the
bumpy field the tractor was moving over. The worker jumped
up onto the platform and attempted to lean against the bin
to gain his balance, but the bin had bounced off its track
on the platform, and he was unable to steady himself.
As he
lost his balance he leaned forward on the work platform and
came into contact with the rear wheel of the tractor. The
tire tread caught his loose jacket and he was unable to free
it. He yelled to the driver that he was caught. His shirt
then became caught and he was pulled off the platform by the
wheel and down to the ground, where the wheel rode over his
chest. The tractor had run over the sledder by the time the
driver became aware of the incident and stopped the tractor.
The
local emergency medical service (EMS) responded to a call
from the field foreman at 12:00 p.m. and arrived about 13
minutes later. Upon arrival the EMS paramedics found an alert
18 year old Hispanic male with normal vital signs, pressed
deeply into the soft dirt of the field and complaining of
chest pain, low back pain and difficulty breathing. He had
an abrasion but no deformity of his lower leg. The paramedics
splinted the injured worker's left leg and immobilized him
by strapping him to a spine board. Paramedics gave the worker
oxygen and started an IV of normal saline, and put him on
a cardiac monitor for observation. After a difficult extrication
the ambulance was enroute to the hospital about 20 minutes
later, and arrived at the hospital emergency room after another
20 minutes (at approximately 1:00 p.m.)
The
hospital admitting diagnosis was crush injury to the chest
with possible fractures on the left side. The injured worker
was admitted for further evaluation, observation, and pain
control, and was discharged two days later after internal
injuries were ruled out. At the time of the worker interview,
12 days after the incident, the worker was at home and stated
that he had no serious injuries and only had mild pain to
the chest area.
PREVENTION STRATEGIES
- The
contractor independently investigated the incident and instituted
a rule that prohibits employees from wearing loose clothing
when driving or working around the tractor/sledding operation.
If the worker had been wearing tight-fitting clothing which
could not become caught by moving parts he would not have
been pulled off the platform by the tractor wheel. This
is an inexpensive and relatively simple way of preventing
machinery entanglement*. * Title 8 California Code of Regulations
3383 (b): "Loose sleeves, tails, ties, lapels, cuffs, or
other loose clothing which can be entangled in moving machinery
shall not be worn."
- Employers
should consider safety guards when modifying tractor or
farm equipment. A guard rail should have been installed
between the bin platform and the large rear wheels of the
tractor. In this incident the sledder could have grabbed
the guard rail to keep from losing his balance, thus avoiding
coming into contact with the wheel. Employers should consider
safety engineering when modifying tractor or farm equipment.
The bins are anchored at the front of the tractor platform,
but at the rear the bins are not anchored to the platform,
allowing the bins to move around when the tractor hits a
bump or rough terrain in the field. The asparagus bins should
be anchored both at the front and the rear when installed
on the tractor platform. In this incident if the bins had
been stabilized the worker might not have lost his balance
and would have avoided coming into contact with the wheel.
- Workers
who are working as a team need to be sure that there is
constant communication and visual contact between themselves.
In this incident if the sledder had been able to signal
the driver that he was caught on the wheel, or if the driver
had stopped the tractor as soon as the sledder was caught,
the worker would not have been pulled off the platform and
subsequently run over.
- Standard
operating procedure should ensure that employees have a
full range of motion. This operation requires employees'
hands to be bound while jumping on and off a moving platform.
In this incident the employee was unable to steady himself
with his hands, and his chest and clothing came into contact
with the rear wheel. Procedures that would leave employees'
hands free should be developed. These might include bundling
asparagus in the field before it is picked up and placed
in the bins.
FURTHER INFORMATION
For further
information concerning this incident or other agriculture-related
injuries, please contact:
NURSE Project
California Occupational Health Program
Berkeley
office:
2151 Berkeley Way, Annex 11
Berkeley, California 94704
(510) 849-5150
Fresno office:
1111 Fulton Mall, Suite 212
Fresno, California 93721
(209) 233-1267
Salinas
office:
1000 South Main St., Suite 306
Salinas, California 93901
(408) 757-2892
Disclaimer
and Reproduction Information: Information in NASD does not
represent NIOSH policy. Information included in NASD appears
by permission of the author and/or copyright holder. More
NASD Review: 04/2002
This
document,
CDHS(COHP)-FI-92-005-10
,
was extracted from a series of the Nurses Using Rural Sentinal
Events (NURSE) project, conducted by the California Occupational
Health Program of the California Department of Health Services,
in conjunction with the National Institute for Occupational
Safety and Health. Publication date: May 1992.
The NURSE (Nurses Using Rural Sentinel Events) project is
conducted by the California Occupational Health Program
of the California Department of Health Services, in conjunction
with the National Institute for Occupational Safety and
Health. The program's goal is to prevent occupational injuries
associated with agriculture. Injuries are reported by hospitals,
emergency medical services, clinics, medical examiners,
and coroners. Selected cases are followed up by conducting
interviews of injured workers, co-workers, employers, and
others involved in the incident. An on-site safety investigation
is also conducted. These investigations provide detailed
information on the worker, the work environment, and the
potential risk factors resulting in the injury. Each investigation
concludes with specific recommendations designed to prevent
injuries, for the use of employers, workers, and others
concerned about health and safety in agriculture.
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