Operational Safety Case Study Student Version In the following pages are six Court Bulletins that describe an incident; read each incident and answer the following questions:

1) What regulation(s) was contravened?

2) What type of controls would have assisted in avoiding this incident? List all that you think would apply. Guidance for answering the questions:

1) What regulation(s) was contravened? When answering this question, provide the name of the regulation and the specific section, for example: O Reg 851 Industrial Establishment S(XX) name of section

2) What type of controls would have assisted in avoiding this incident and why?

List all that you think would apply. Why do you think this control would assist in avoiding the incident, or, if you determine that there is no control for a specific type of control, identify why?

Why do you think this control would assist in avoiding the incident, or, if you determine that there is no control for a specific type of control, identify why?

Type of Control Description of Control Why or why not?

Elimination

Substitution

Engineering

Administration

PPE

1) Description of Offence: A worker was fatally injured when a mini-excavator being operated in a pipe tipped over. Background: On June 21, 2018, a construction crew was working on a construction project. Work was being performed in an underground pipe. A supervisor was operating a mini-excavator that had been lowered down a shaft and into the underground pipe. The diameter of the pipe measured 1.8 meters at that location. The tip over protection system (TOPS) of the mini-excavator had been removed prior to it being lowered down and into the pipe. It is not known when the TOPS was removed or by whom. A TOPS protects a mini-excavator from tipping over and can protect an operator of a mini-excavator from overhead hazards. The supervisor decided to operate the mini-excavator. While operating it the supervisor was fatally injured when the front tracks of the machine lifted, causing the worker to be pinned between the top of the inside of the pipe and parts of the mini-excavator.

2) Description of Offence: A worker was injured while repairing an elevator. Background: On February 5, 2019, a worker and co-worker were in the process of checking the gap clearance on the recently replaced brake assembly on an elevator. The task involved using a gauge to measure the gap between the drum and the brae brake pad. The co-worker was at the control panel of the elevator. The controls were set on manual override. The co-worker pressed the control to move the elevator in the up direction which resulted in the sheave (pulley) rotating counterclockwise. This created a pinch point between the cables and the sheave. The worker was caught in this pinch point; an arm was pulled into the cables and rotated at least half-way around the sheave. The co-worker immediately reversed the direction of the elevator which freed the arm. The worker sustained injuries and required surgery.

3) Description of Offence: A worker who was removing snow from the roof of a shed fell through a skylight. Background: In the yard of the workplace was a shed in which lumber and other building supplies were stored. In the winter of 2018-19 there was a large accumulation of snow on this building. In December/January, structural deformation of a horizontal support beam on the west side of the shed was observed. A third-party contractor was employed to remove the snow load with the assistance of the accused employees. A few weeks later, further bowing and cracking of another structural support beam on the east side was observed. On February 27, 2019 a yard supervisor assembled two employees for the purpose of removing the accumulated snow load to prevent further structural damage to the building. The third-party contractor was not engaged to perform work on this occasion. That morning the three employees held a brief meeting to discuss the snow clearing work. One of the topics was the presence of skylights on the shed roof. These were sheets of corrugated plastic, each 2 feet wide and 7 feet long, mounted flush to the shingled roof surface. One of the skylights was at a location near the snow to be cleared. No identification markers were placed to demarcate the skylight, which was more than 17 feet above the floor of the shed. All three workers attended on the roof of the shed and began pushing snow off the sloped roof, which was more than 11 feet above the ground at the edge. None of the three were wearing any type of fall protection equipment and no guardrails were in place at the roof edge or around the skylights. There had been no discussion of fall protection at the morning meeting and no fall protection equipment was provided to the workers. After lunch one of the workers returned to the roof of the shed and continued clearing snow. While doing so the worker stepped on the skylight, broke through and fell to the ground below, suffering injuries.

4) Description of Offence: A worker who was cleaning excess packaging from a machine was injured after removing interlocking guards from the front of the machine. Background: On October 12, 2018, a temporary worker was cleaning a hot dog loader/packer machine. The worker removed the interlocking guards from the front of the machine to clean any excess plastic packaging. This exposed the machine and its pre-heating plate. As the worker was attempting to remove excess plastic, the machine was actuated and the worker was injured by the machine's plates. The injured worker was taken to hospital.

5) Description of Offence: A worker suffered critical injuries after being struck by a moving forklift that was operating in reverse. Background: On September 16, 2018, a worker was pulling a load of scrap plastic sheeting over to the scrap plastic grinder and was struck by a forklift. The operator of the forklift had picked up a skid of product from the shrink wrapper and the forklift was reversing when it struck the worker, who fell and was partially run over. The worker suffered critical injuries.

6) Description of Offence: A worker suffered critical injuries after being caught and dragged into a conveyor. Background: On September 20, 2018, a worker was working as part of the clean-up crew in the mushroom-growing facility's spawn area. The worker was washing down the concrete ramp to the spawn area's overhead door and was called over to work on cleaning up the compost which had been knocked off the green feed hopper onto the concrete pad below. The green feed conveyor is located outside the spawn area buildings. This equipment feeds the green compost up into the spawn area for production. It is an angled conveyor and hopper, which consists of chain-driven cross bars and a fixed flat pan conveyor. The bars move up the flat pan, dragging material to the top. The worker began to assist the lead hand by cleaning the compost from under and around the conveyor, which was stationary at the time. While this work was being performed, the lead hand went to the control panel, removed the lock and started the conveyor, which began to move. The worker started to walk in front of the conveyor, slipped on some wet compost on the ground and fell. The worker reached out and grabbed one of the conveyor bars to try to stop the fall. In so doing, the worker was caught in the bars of the moving conveyor, and was being dragged up and into the conveyor. As a result of being caught and dragged, the worker suffered multiple critical injuries