Michelman Rod Coater Accident

MASE Product Failure Injury Report

Product involved: Michelman Rod Coater MRC 1000

What happened:  Worker became entangled in nip point while cleaning off roller

Injuries: Unknown

Recommendations:  Ensure adequate interlocking to prevent access to moving machinery, use of brakes and interlocking to prevent removal of access panels while machine is coming to a stop, two hand jog control and access control for cleaning operations, warnings, training

OSHA/Standard violations?: Unknown

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Stoughton Trailer Failure

MASE Product Failure Injury Report

Product involved: Stoughton Hopper trailer

What happened:  Trailer structure collapsed under weight of load while crossing railroad tracks

Injuries: Unknown

Recommendations: Design analysis of structure to determine weakness, design trailer structure to withstand dynamic loading, increase structural component size to prevent failure

OSHA/Standard violations?: No

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Hosley Ottoman Failure

MASE Product Failure Injury Report

Product involved: Hosley Faux Leather Stool H95522WL

What happened:  Ottoman leg failed under weight of user, causing stool to collapse

Injuries: Unknown

Recommendations: Stronger connection between legs and structure of stool, thicker structural components

OSHA/Standard violations?: No

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Versaladder articulated ladder Injury

MASE Product Failure Injury Report

Product involved: Versaladder Special Purpose Folding Ladder, Model 13093 rated 300 lb, 12 ft 4.6 in length”.  

What happened:  Ladder user was using the Versaladder when a hinge collapsed causing the user to fall from the ladder.  Ladder was inspected.  No defects were found.

Injuries: Unknown

Recommendations: Making the indicator of the hinge clear and obvious whether the hinge is locked or unlocked.  Current design is not intuitive and there is no quick way to determine if the hinges are safely locked.  Open hinge design allows easy access to dirt and debris, potentially making hinge stick and false lock.

OSHA/Standard violations?: No

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JCB backhoe Injury

MASE Product Failure Injury Report

Product involved: JCB backhoe

What happened: Person was putting in a sewer line near an existing water supply line.  To ensure the water line did not get hit, one worker would use a backhoe to dig, then the other worker would get into the hole and dig by hand for a few inches.  Person in hole got hit by backhoe bucket when operator tried to move it right, which it did, but then swung left violently. 

 

Injuries: None listed.

Findings: Appears to be a case of out-of-adjustment hydraulic controls.  By the time the unit was inspected, the cover over the foot pedal controls had been removed. The rod that went to the foot pedal control had been recently adjusted.  There is a distinct difference in the rod adjustments on the other valves.  The linkage threads on the crucial valve are clean as are the nut and clevis. Someone even tried to spot weld the adjustment device so that it would not loosen. The foot pedals that control the left-right movement of the boom looked new. The paint was not worn on the pedal.

OSHA/Standard violations: None found

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Racked Aluminum Stepladder Causes Fall

MASE Product Failure Injury Report

Product involved: Type III four-foot aluminum ladder

What happened:  Stepladder positioned facing a wall.  Person working on the ladder.  Ladder became racked, and collapsed when weight of user moved outside of footprint of ladder.

Injuries:  None

Recommendations: Increase stability of ladder to prevent racking and loss of balance.

OSHA/Standard violations?:No

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Grain bin and auger system Fatality

MASE Product Failure Injury Report

Product involved: David Manufacturing Company (DMC)/ The GSI group (Grain Systems)

What happened:  Two men were unloading grain bins.  One man took a load of grain out.  Other worker stated he was going to let sweep auger empty the grain bin out until it wouldn't move any more grain.  First worker returned, helped second worker for short time, then left.  He returned 3-5 minutes later to find his coworker unresponsive on the bin floor.  Auger shaft had fractured, sending the broken metal part shooting at a high rate of speed which impacted the worker in the head.

Injuries: Death

Recommendations: Needed to be guarded, have warnings, “Deadman” switch to control the power with personnel in bin, and interlocks. Also auger could not resist the predictable cyclic stresses acting on the auger - redesign could solve this problem.

OSHA/Standard violations?: No

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Davidson Aluminum Stepladder

MASE Product Failure Injury Report

Product involved: Davidson Type III Model 527-06 aluminum ladder.

What happened:  Prior to the accident, the ladder was positioned approximately parallel to the wall. The front and rear feet of the ladder were approximately three inches away from the wall, with the wall to the right of the ladder. User fell.  After the fall, the ladder was lying on its side on the floor. Ladder user was lying on the floor in front of the ladder. After the accident, it was observed that the left rear ladder rail was bent.

Injuries: Unknown

Recommendations: Increase ladder stability to decrease racking of ladder

OSHA/Standard violations?:No

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Ford Tractor Injury

MASE Product Failure Injury Report

Product involved Ford Model 6600 tractor with front-end loader attached

What happened: Tractor operator traveling on a slight slope with a load of dirt in the front-end loader.  He raised the bucket as he approached the dump location, which raised the center of gravity to the point where the tractor overturned to the side.

Injuries: Death

Recommendations: Roll Over Protective Structure (ROPS) and a seat belt

OSHA/Standard violations: None found

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Red Lobster Slip-&-Fall Injury

MASE Product Failure Injury Report

Product involved: Elevated booth in Red Lobster

What happened:  Restaurant patron exiting elevated booth, feet slipped out from under her

Injuries: Unknown

Recommendations: Put booths on floor level to eliminate this hazard.

OSHA/Standard violations? No

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Bleacher Fall Injury

MASE Product Failure Injury Report

Product involved: School bleachers

What happened: Girl was walking up bleachers. She stepped out of the aisle to let a person pass, then stepped onto a bleacher seat, and fell.  She stated that the seat popped forward when she stepped on the bleacher seat.

Injuries: She had hurt her lower back and shin.

Findings: There was no evidence of loose fasteners. There was no evidence of maintenance performed by the school after the accident to fix something related to the accident.  Appears to be a slip and fall case.

OSHA/Standard violations?  No

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Murray Lawnmower Injury

MASE Product Failure Injury Report

Product involved: Murray 12.5 hp riding mower

What happened: While loading a lawnmower in a truck by manually lifting it, the blade engagement lever was actuated, with the motor running.

Injuries: Finger amputation

Recommendations: A positive locking blade engagement mechanism to prevent inadvertent activation

OSHA/Standard violations: None found

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DeWalt ½"-drill Injury

MASE Product Failure Injury Report

Product involved: DeWalt ½"-drill model DW 235G

What happened:  Man was using the drill without a handle when the high torque caused injury to his hand. The handle had been lost and was unavailable.

Injuries: To hand

Recommendations: Make handle permanently attached.

OSHA/Standard violations? No

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Davidson Fiberglass Stepladder Type IA Accident

MASE Product Failure Injury Report

Product involved: Louisville Type IA 12-foot Fiberglass Stepladder, Model No. FS1012

What happened: Ladder was set up leaning against a wall, on a wooden box.  Left rear leg was unsupported and right rear leg was supported, resulting in the ladder walking off of the box, causing the ladder user to fall, and impact the ladder.

Injuries: Unknown

Recommendations: Locking clip to keep ladder legs together when used in this configuration

OSHA/Standard violations?:No

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Davidson Aluminum Stepladder Injury

MASE Product Failure Injury Report

Product involved: Davidson G 527-06 Aluminum Stepladder

What happened:  Woman was applying tape to a wall she was painting.  She had ascended to the third step of the stepladder.  While she applied tape, the ladder became racked, and then failed as the ladder tipped over.

Recommendations: Increase stability of ladder by widening base of ladder.  The ladder could have been made stronger by increasing the thickness of the materials and by more appropriate bracing. Ladder cannot withstand dynamic forces.

OSHA/Standard violations?: No violations, although material was found to not meet minimum specifications.

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Concrete Truck Driver Injury Operator Compartment

MASE Product Failure Injury Report

Product involved: 1997 Advance Mixer concrete truck

What happened:  Driver violently struck his head on the low ceiling of the cab.  These impacts caused his head and neck to bend to the side, resulting in injuries

Recommendations: Use off-road standards for the hybrid vehicle that is both a highway and off-road vehicle. 

OSHA/Standard violations? Advance Mixer cab does not meet the "Operator Space Envelope Dimensions For Off-Road Machines", SAE J154, June 92.  There is not enough room for the driver as is evident by this standard.

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Interkal Bleacher Fall Injury

MASE Product Failure Injury Report

Product involved: Interkal bleachers

What happened: Female stepped onto bleacher seat, seat allegedly popped forward, she fell, seat allegedly reseated itself

Injuries: Lower back and shin injury

Findings: Determined to be a slip and fall.  No failure of fasteners or seat module.  Product appears to meet appropriate design criteria.

OSHA/Standard violations?: No

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Bauer Fiberglass Stepladder Injury

MASE Product Failure Injury Report

Product involved: Six-foot Bauer Fiberglass stepladder

What happened: Ladder user was standing on fourth rung of ladder.  Stepladder failed suddenly to right when a ladder rail split lengthwise down the rail, causing him to fall to the right and land on the ground.

Injuries: Shoulder injury requiring surgery

Recommendations:  Reinforcement, use a material less susceptible to aging effects

OSHA/Standard violations?: No

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1997 Honda TRX ATV Injury

MASE Product Failure Injury Report

Product involved: 1997 Honda TRX 300 FW

What happened:  ATV operator was making a right-hand turn at about 10 mph when vehicle rolled over onto the operator.

Injuries: severe internal injuries/death

Recommendations: Limited slip differentials, ROPS with a seatbelt

OSHA/Standard violations?: No

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610 Long Farm Tractor Injury

MASE Product Failure Injury Report

Product involved: 610 Long Farm Tractor

What happened:  Tractor rollover in a ditch

Injuries: Death

Recommendations: Rollover Protection System (ROPS) with seat belt would have prevented this death

OSHA/Standard violations?: No

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Cincinnati Power Press Injury

MASE Product Failure Injury Report

Product involved: Cincinnati Hydraulic Press Brake

What happened:  Worker was bending sheet metal in press brake, and was positioning metal in press when the press cycled unexpectedly.  Worker’s hand was caught in press.

Injuries: Crushing, amputation of fingers

Recommendations: Interlocked barrier guard, light curtain, two-hand control

OSHA/Standard violations?: No

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VersaLadder Collapse Due to False-Locked Hinge

MASE Product Failure Injury Report

Product involved: VersaLadder Articulating Aluminum Ladder

What happened:  Person using Versaladder in straight ladder configuration.  The ladder collapsed when the user was part way up the ladder due to a hinge collapsing, sending the user falling to the ground.

Injuries: Back and head injuries

Recommendations:  Use a hinge lock with a uniform cross section to prevent partial engagement of lock, protect hinge to prevent increased friction in joint due to rust, dirt, and debris.  Also more intuitive locking mechanisms may help increase proper use.

OSHA/Standard violations?: No

Werner D 1532-2 Extension Ladder Failure

MASE Product Failure Injury Report

Product involved: Werner D-1532-2

What happened:  Workers were applying tar to roofs.  Ladder was moved around throughout the day.  As one worker went to descend from a roof, the extension ladder collapsed, telescoping on itself, until the ladder fell from the eave of the roof.

Injuries: Back, leg injuries

Recommendations:  Use a rung engagement device with a positive acting mechanism to prevent fly-lock where fly section tip partially engages a ladder rung.  Additional safety systems to prevent ladder collapse can be added including a method to lock a rung from one extension ladder section to a rung on the second extension ladder section. 

OSHA/Standard violations?: No

Cuprum Extension Ladder Failure

MASE Product Failure Injury Report

Product involved: Cuprum Extension Ladder

What happened:  Homeowner was in process of cleaning the gutters of his two story home.  He climbed onto roof from ladder, and his sons moved the ladder to rest on the gutter of a roof section with a different eave height.  The ladder height was likely adjusted at this point for the different roof elevation.  When the homeowner got back onto the extension ladder and started to climb downwards, the ladder telescoped on itself, then stopped, sending the homeowner falling to a deck below.  The ladder most likely experienced false lock when the height of the ladder was adjusted.  False-locked ladders are ladders that are partially held at an extended condition but the locking mechanism is not fully engaged.  False-locked ladders can easily collapse.

Injuries: Back, leg injuries

Recommendations:  Use a rung engagement device with a positive acting mechanism.  Additional safety systems to prevent ladder collapse can be added including a method to lock a rung from one extension ladder section to a rung on the second extension ladder section. 

OSHA/Standard violations?: No

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Doringer Cold Saw Accident

Doringer Cold Saw Accident

MASE Product Failure Injury Report

Product involved: Doringer Cold Cutting Chop Saw

What happened:  Worker’s hand caught in saw when he attempted to change the miter angle of the saw with the saw running.  This was done because the cooling fluid would take several minutes to begin flowing upon startup, so the saw was left running all day, and shut off at the circuit breaker at the end of the day. 

Injuries: Severe laceration

Recommendations:  Adjust guard for optimal protection with each particular stock being used, use a blade guard that completely surrounds blade when in the upright position, ensure proper operating procedures for miter adjustment – ensuring that power to the saw is off during adjustment or maintenance.

OSHA/Standard violations?: Not cited

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Upright Self-Propelled Elevating Work Platform Accident

MASE Product Failure Injury Report

Product involved: Upright X20N Personnel Lift

What happened:  A worker was using the personnel lift to perform construction tasks at elevation.  As he was moving the lift across the floor, in an elevated position, the lift encountered a small bump, which resulted in the tipping of the elevated lift.

Injuries: Broken bones, internal injuries

Recommendations:  Interlock outriggers to ensure their use

OSHA/Standard violations?: Unit not tested to determine conformance to ANSI A92.6.  This ANSI standard requires personnel lifts to pass a dynamic curb test where the unit is driven at maximum speed into an obstacle.  Interlocks are required if the speed of the lift must be reduced to pass the ANSI test requirements.  Interlocks are also required if the outriggers are necessary to meet test criteria.

Cuprum Eight Foot Aluminum Stepladder Failure

MASE Product Failure Injury Report

Product involved: Cuprum Eight-Foot Aluminum Stepladder

What happened:  A man was descending this ladder.  As he placed his foot on the sixth step, the front legs of the ladder fractured, causing the ladder to collapse, and send the person descending the ladder falling to the ground.  The legs of the ladder were straight and not bent.  The ladder failed at riveted connections.  Hairline cracks were found at other riveted connections.

Injuries: Broken right lower leg

Recommendations:  Ensure material consistency in product, use aluminum of high enough strength to withstand forces encountered during use, strengthen ladder to reduce racking characteristics of ladder.

OSHA/Standard violations?: Unknown

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Toyota Forklift

MASE Product Failure Injury Report

Product involved: Toyota forklift

What happened:  Workers were being raised and lowered from an elevated position using a forklift with a pallet to stand on.  After raising two workers to the elevated position, the driver of the forklift reportedly left the forklift.  One of the workers climbed down the mast of the forklift.  This worker became crushed between the top of the lift and masts of the forklift.

Injuries: Fatal

Recommendations:  Guarding the pinch and shear points of the forklift, particularly safeguarding the mast assembly of the forklift

OSHA violations?: Yes, failure to guard an elevated position to protect workers from falling, needed guarding on side of platform adjacent to forklift mast, failure to provide training

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