Date of incident: May 2020
Notice of incident number: 2020178250021
Employer: Farm services company

Incident summary
At a dairy farm, a worker was using a manure‑loading pipe to transfer liquefied manure from a manure pit into a manure spreader. A piece of rubber tube attached to the loading pipe became detached and fell into the manure spreader tank. The worker drained the manure from the tank but was then unable to retrieve the rubber tube. He entered the tank to retrieve the rubber tube. While inside the tank, he became unconscious. Two other workers entered the tank and rescued the unconscious worker.

Investigation conclusions

Cause

• Entry into confined space with hazardous atmosphere. The worker entered a confined space, the tank of a manure spreader, to retrieve a rubber tube that had fallen into the tank. While inside the tank and as a result of exposure to a hazardous atmosphere, he lost consciousness and had to be rescued by two other workers.

Contributing factors

• Manufacturer’s instructions were not followed. The manufacturer installed a warning label on the manure spreader warning of the potential for toxic gases to be present. The manufacturer’s warning label states: “DO NOT ENTER.” The dangers of entering the manure spreader tank are also explained in further detail in the instruction manual. The employer did not ensure that a copy of the instruction manual was readily available to workers using the manure spreader or that the worker who lost consciousness was adequately familiar with the manufacturer’s instructions.
• Inadequate training and instruction. The employer failed to adequately train and instruct the worker in regard to confined spaces in the workplace. The worker was not provided with information, training, or instruction regarding confined space entries. The employer permitted the worker, as well as other workers it employed, to perform confined space entries even though it had not established a confined space entry program outlining the required procedures to ensure worker health and safety.
• Inadequate management of workplace health and safety. The employer did not conduct regular inspections to identify and mitigate the hazards in the workplace. Regular monthly safety meetings were not conducted to discuss health and safety matters. The employer also did not have a qualified first aid attendant and first aid kit at the worksite. These deficiencies, as well as the circumstances of the incident, demonstrate that the employer’s workplace health and safety management was inadequate.

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