California
NURSE Project
A summary
of this document is available in english and spanish.
(Un resumen de este documento está disponible en inglés y español.)
SUMMARY: CASE
193-378-01
A forklift
driver was moving boxes at a raisin packaging plant. The forklift
he was driving was rented. It kept losing radiator fluid out
the radiator overflow hose, so every few hours he added water.
Suddenly,
the radiator cap blew off his forklift. Hot radiator fluid
scorched the skin on his back and arm. He jumped off the forklift
and bruised his right leg. A co-worker quickly poured cold
water over the burned forklift driver. Then a supervisor drove
him to the doctor.
An ambulance
immediately moved him to the burn unit at another medical
center. He spent 13 days in the hospital with 20% total body
burns.
How
could this injury have been prevented?
- Employers
should provide ongoing forklift safety training to workers.
This training should include how to handle minor mechanical
problems.
- Workers
should report equipment malfunctions to supervisors.
- Workers
and employers should call 911 if someone has a burn injury.
BACKGROUND
On August
31, 1993, NURSE staff received a written report of an agricultural
injury from a Regional Trauma Center. On August 27, 1993,
while a forklift operator was moving boxes he received first
and second degree burns to his left arm and back from hot
radiator fluid. The radiator cap blew off the forklift he
was operating. The skin on his back and left arm was sprayed
with hot radiator fluid, leaving them red and blistering.
A nurse
from the NURSE Project interviewed the forklift operator by
telephone on September 13, 1993. On September 16, 1993, the
safety engineer discussed the incident with the personnel
manager, also responsible for plant safety, and conducted
an on-site investigation on September 17, 1993.
The
California Occupational Health and Safety Administration (Cal-OSHA)
was not notified and did not investigate this incident.
This
incident occurred at a raisin processing and packaging plant.
This plant employs approximately 150- 160 full-time workers
(working 38+ weeks per year) and, at most, 40 seasonal workers
(working 13-37 weeks per year) during the peak summer harvest
season. The injured forklift operator was employed as a forklift
operator for the past twenty years at this plant.
The
safety engineer reviewed the employer's written injury and
illness prevention program and noted that it did address all
points as 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: 1. designated
safety person responsible for implementing the program; 2.
mode for ensuring employee compliance; 3. hazard communication;
4. hazard evaluation through periodic inspections; 5. injury
investigation procedures; 6. intervention process for correcting
hazards; and 7. provide safety training and instruction.)
The safety engineer also reviewed specific written safety
policies addressing forklift operation. Videos are also used
for forklift safety training. However, the forklift operator
stated the last forklift safety training he had was five years
ago.
INCIDENT
On August
27, 1993, at approximately 2:15 p.m., a 52 year-old male Hispanic
forklift operator was moving boxes inside a raisin processing
and packaging plant. Suddenly, the radiator cap blew off the
forklift he was operating and sprayed his back and left arm
with hot radiator fluid.
The
forklift operator turned to see what sprayed him, then jumped
over the right side control levers and bruised his right leg.
He ran to a nearby co-worker who poured cold water over him
and helped him to the office. A supervisor transported the
injured forklift operator by private vehicle to a medical
office, arriving approximately 17 minutes after the incident.
The medical office immediately called an ambulance to transfer
him to the burn unit at a Regional Trauma Center. They injected
the injured forklift operator with pain medication.
The
injured forklift operator was admitted to the burn unit, where
his burns were cleaned, dressed, and he was given pain medication.
Due to him developing pneumonia he was hospitalized for 13
days, with 20% total body first and second degree surface
burns to the left arm and back. After release from the hospital
he was to return to the burn unit for follow-up. The nurse
from the NURSE Project visited the forklift operator at his
home one month after the incident. At this time he still did
not know when he would return to work.
To keep
up with the packaging demand at peak harvest times, some forklifts
are leased at this raisin processing and packaging plant.
The forklift involved in this incident was leased approximately
ten days before the incident. The lease company was responsible
for the upkeep on the forklift. The plant personnel manager
reported there had been no mechanical problems with the forklift
prior to the incident.
However,
the forklift operator reported that earlier in the day the
forklift was losing radiator fluid out the radiator overflow
hose, so he added water every 2-3 hours. Adding water was
an effort to prevent overheating because radiator fluid was
being lost. Although a light on the dash of the forklift is
supposed to shine when it gets too hot, the forklift operator
stated this light never came on.
The
safety engineer from the NURSE Project was unable to inspect
the cap because a private investigator, hired by the plant's
workers compensation insurance, had possession of it. However,
she reported there were no visible defects to it. The cap's
rating was 16 pounds per square inch (PSI). This is a safety
mechanism which forces the cap to slowly release pressure
if it exceeds 16 PSIs. The private investigator stated she
was unsure if a pressure check would be completed to determine
if the cap performed at its specified rating. Consequently,
it is unclear why the radiator cap blew off.
PREVENTION STRATEGIES
- Workers
should report equipment malfunctions to supervisors. If
the forklift operator had reported the loss of radiator
fluid to the supervisor, the forklift may not have been
used until it was repaired. If so, the operator may not
have been burned by the hot radiator fluid (Title 8 California
Code of Regulations 3664(a)(7): "Drivers shall check vehicle
at least once per shift, and if it is to be found unsafe,
the matter shall be reported immediately...")
- Employers
should provide ongoing forklift safety training to workers.
Although the plant had a written safety program and training
specific to forklift operation, the injured worker had not
received training on safe forklift operating procedures
for at least five years. In this incident, if the operator
had received ongoing training that addressed forklift maintenance
and how to handle malfunctions, the injured worker may have
not continuously added water (Title 8 California Code of
Regulations 3203: Injury and Illness Prevention Program.)
- Forklift
manufacturers should design equipment with safety in mind.
If this forklift had a hinged, metal latching door covering
the radiator hole leading to the radiator cap, the hot coolant
would be deviated away from the operator even if the cap
blew off. A rubber seal could also be placed around the
metal guard to provide a waterproof barrier, while still
providing easy access to the radiator cap. In this incident,
if the forklift was equipped with this safety feature, the
forklift operator may not have been burned (Title 8 California
Code of Regulations 3664(b)(32): "Every employee who operates
an industrial/ agricultural truck or tractor shall be instructed
in the following procedures...")
- Work
crews, including supervisors, should have an adequate emergency
medical response procedure. Crews should be trained to immediately
call 911 in an emergency. In this incident, the supervisor
should have called 911 before transporting the injured worker.
Also, calling 911 may have expedited medical treatment to
the injured worker.
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(COHB)-FI-93-005-30
,
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: November 1993.
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.
|