Date of incident: December 2014
Notice of incident number: 2014110750126
Employers: Trucking company; pulp and paper mill

Incident summary

A truck driver fell into a wood chip reclaim pit at a pulp and paper mill under unknown circumstances while unloading wood chips from a trailer. The worker lost consciousness and was transported by a conveyor system into a wood chip storage silo, where the worker became buried in wood chips. The large quantity of wood chips hampered the recovery of the worker because the rescuers needed to enter into a confined space with entrapment hazards. The worker sustained fatal injuries.

Investigation conclusions

Causes

• Trailer permitted to be parked too close to the reclaim pit: The truck driver parked the truck too close to the reclaim pit to be able to safely open the doors prior to unloading. He did not have enough room to be able to open the trailer doors without being very close to the reclaim pit. The mat of chips on the ground under the worker may have given way as evidenced by a chunk of chips missing in the area where he likely would have stood. This may have been what caused the worker to fall into the reclaim pit.
• Hazards not identified and risk assessment not conducted: The pulp mill failed to exercise adequate oversight of work activities at the truck dump and reclaim pit area. As the prime contractor, the pulp mill had transferred safety responsibility onto a contractor and did not recognize that unsafe work practices had developed. The reclaim pit hazards were not recognized for the risk that they presented to workers and were not identified in the any of the truck driver inductions. Risk assessments were not undertaken to control the hazards. No safe work procedures were developed for truck drivers working around the reclaim pit. Tasks included opening trailer doors, backing trucks into the reclaim pit to dump, and taking chip samples for quality assurance. These activities put workers or equipment at risk of falling into the pit.
• Failure to prevent workers from working in close proximity to the pit: The reclaim pit was not adequately guarded to prevent worker and equipment access. Workers and equipment had previously fallen into the reclaim pit because there was no physical barrier between the work area and the reclaim pit. No signage was posted at the reclaim pit warning of any hazard.

Underlying factors

• Failure of the prime contractor’s internal policies: The prime contractor failed to identify hazards and assess and control risks as required within its health and safety program. The prime contractor conducts regular inspections of the workplace with the objective of identifying hazardous conditions and makes recommendations to mitigate the hazards. Similarly, the prime contractor has a process for hazard reporting in which all workers are obligated to report hazards they observe or become aware of. The report of a hazard is to be further investigated, and again, recommendations made to control the hazard. These mechanisms within the health and safety program failed to identify the hazardous conditions and activities at the reclaim pit, despite the conditions and activities having existed for many years.
• Failure to report incidents: Just two months prior to this incident, another truck driver had fallen into the pit. Had that driver reported the incident to the supervisor and the incident been properly investigated and reported to the prime contractor, the hazards presented by work at the reclaim pit would have been identified and corrective actions might have been undertaken.
• Truck driver not provided area orientation, induction: There was no evidence of the worker having received an orientation to the chip dumping area, despite a mill policy requiring this to be done. This led to a conclusion that the prime contractor failed to provide an area-specific induction to the worker. An induction should have provided an opportunity for the mill to review hazards in the chip dumping area, and safe work practices to ensure the safety of the workers.
• Truck driver in the bight: The doors on this particular trailer were of the barn-style type, requiring the worker to stand in front of the two doors and then open one door to the right and one door to the left. Of necessity, opening the doors would require the worker to step toward the open pit. He was also at risk of being buried in wood chips, struck by the door, or struck by any debris in the trailer when opening the doors.

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