Date of incident: September 2013
Notice of incident number: 2013157270247
Employer: Golf course

Incident Summary
A grounds maintenance worker at a golf course removed the wheel of a fairway mower and placed the exposed axle on a jack stand in order to change a leaking hydraulic hose. The worker went under the mower to loosen the fitting, while a co-worker held the second part of the fitting, from above, with a wrench. When the worker tried to loosen the fitting, the mower fell from the jack stand onto him, resulting in a serious injury.

Investigation conclusions
Cause

• Mower fell onto worker: The grounds maintenance worker removed one wheel from a three-wheeled fairway mower and, using a single jack stand, elevated its axle to access and remove a hydraulic hose. While the worker was under the mower, it fell off the jack stand onto the worker.

Underlying factors

• Unsafe work procedure: It was not necessary to elevate the mower and position a worker under it to facilitate the removal and replacement of the hydraulic hose. An unsafe work procedure was followed.
• Unsecure mobile equipment: The mower was not properly secured against inadvertent movement before working on it. The parking brake did not function and could not be engaged, the wheels were not chocked, and two jack stands were not used as required.
• Inadequate supervision: This workplace did not have a safety management system. Although the injured worker had replaced hydraulic hoses before the incident, the employer did not provide him with adequate instruction and supervision to ensure his health and safety while working on the mower.

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