Date of incident: December 2020
Notice of incident number: 2020157560009
Employer: Composting company

Incident summary
At a food composting site, a young and new worker was inside a large digester bin, clearing composted material out of the bin. The worker was standing on top of an auger at the bottom of the bin. The auger began moving unexpectedly and crushed the worker against the side wall of the bin. The worker sustained serious injuries.

Investigation conclusions

Cause

• Energized equipment was turned on. Workers were required to enter the digester bin in order to clear it out and were exposed to an energized auger that was able to start turning while they were next to or on top of it. The worker entered the bin to clear it of composted material when the auger on the bottom of the bin was not locked out. Another worker started up the auger from a control panel across the yard and the worker inside the bin was drawn into the auger.

Contributing factors

• Failure to identify hazards and conduct risk assessments. The employer failed to recognize that the work process its workers used to clear material from the bin included two hazards that posed a high risk of injury: entry into a confined space and unexpected energization of equipment. The employer should have developed controls based on a hazard identification and risk assessment.
• Lack of safe work procedures. The employer had not developed written safe work procedures for clearing the digester bin. Safe work procedures for lockout and confined space entry should have been developed. Workers entering digester bins should have been trained based on written procedures that included all the necessary steps required to clear out the bins in a safe manner.
• Inadequate instruction, training, and supervision. Young and new workers with little to no experience were performing high-risk work activities. Neither the workers nor their supervisor received a level of instruction, training, and supervision adequate to safely perform the work being conducted.

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