TECHNICIAN CRUSHED BY FRONT END
LOADER’S BUCKET LIFTING MECHANISM
Type of Incident: Fatality
Date of Incident: June 15, 2012
File: F-99995
TABLE OF CONTENTS
SECTION TITLE PAGE NUMBER
1.0 DATE AND TIME OF INCIDENT 4
2.0 NAMES & ADDRESSES OF PRINCIPAL PARTIES 4
2.1 Owner 4
2.2 Contractor 4
2.3 Employer 4
2.4 Worker/Co-Owner 4
3.0 DESCRIPTIONS OF PRINCIPAL PARTIES 5
3.1 Owner 5
3.2 Contractor 5
3.3 Employer 5
3.6 Worker/Co-Owner 5
4.0 LOCATION OF INCIDENT 5
5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 6
5.1 Equipment and Material 6
5.2 Observations 6
6.0 NARRATIVE DESCRIPTION OF INCIDENT 7
7.0 ANALYSIS 8
7.1 Direct Cause 8
7.2 Contributing Factors 8
8.0 FOLLOW-UP/ ACTION TAKEN 9
8.1 Occupational Health and Safety 9
8.2 Industry 9
8.3 Additional Measures 9
9.0 SIGNATURES 10
10.0 ATTACHMENTS 10
Attachment A Map
Attachment B Diagram
Attachment C Photographs
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SECTION 1.0 DATE AND TIME OF INCIDENT
1.1 The incident occurred on June 15, 2012 at approximately 1:30 p.m.
SECTION 2.0 NAMES AND ADDRESSES OF PRINCIPAL PARTIES
2.1 Owner
2.1.1 Battle River Transit Mix (division of FTC Construction Ltd.)
602 – 4th Avenue South
Wainwright, Alberta T9W 1T3
2.2 Contractor
2.2.1 Battle River Transit Mix (division of FTC Construction Ltd.)
602 – 4th Avenue South
Wainwright, Alberta T9W 1T3
2.3 Employer
2.3.1 Alberta Laser and Tech Services Ltd.
9823 - 33 Avenue NW
Edmonton, Alberta T6N 1B6
2.4 Worker/Co-Owner
2.4.1 Technician (************)
***************
************ ******* ********
SECTION 3.0 DESCRIPTIONS OF PRINCIPAL PARTIES
3.1 As a business owner, Battle River Transit Mix is a small concrete mixing, concrete
delivery, concrete pumping and aggregates supply operation for the city of
Wainwright and surrounding area. The business has been operational for
approximately 11 years and has 7 employees including the owner.
3.2 As a contractor, Battle River Transit Mix occasionally hires other businesses to
complete service work on equipment used in the business described in paragraph 3.1.
Battle River Transit Mix had retained the services of Alberta Laser and Tech Services
Ltd. to install and service an electronic scale system for determining the weight of
product in the wheeled loader’s front end bucket.
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3.3 Alberta Laser and Tech Services Ltd. is a small business with two employees who are
co-owners of the company. The primary function of this business is the sale of, and
installation of, electronic weighing equipment for various industrial applications. At
the location of the incident, the Alberta Laser and Tech Service Ltd’s workers were
servicing the electronic weighing equipment that had been installed (approximately 3
years earlier) on a wheeled front-end loading machine. The electronic scale system
weighed the contents of the bucket mounted on the front of the machine.
3.4 The Technician (************) handled the installation and servicing of the
Compuload weighing system for various equipment. He was a partner/co-owner in
the business called Alberta Laser and Tech Services Ltd. The other partner/co-owner
Salesman (*************) accompanied the Technician (************) on all field
trips but did not participate in any of the technical tasks with the Compuload
weighing equipment.
SECTION 4.0 LOCATION OF INCIDENT
4.1 The Battle River Transit Mix equipment shop is located within the concrete mixing
plant property at the south end of the city of Wainwright. The incident occurred
inside the equipment shop of the mixing plant. (Attachment A, Map and Attachment
C, Photograph 1).
SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS
5.1 Equipment and Material
5.1.1 Wheeled Front-End Loader
Manufacturer – Volvo Construction Equipment North America Inc.
Model – L60F
Serial No. – **********
(Attachment C, – Photograph 2)
5.1.2 Transducer 1
Manufacturer – Compuload
Model – KPT 10000
Serial No. – ******
(Attachment C, – Photograph 3)
5.1.3 Transducer 2
Manufacturer – Compuload
Model – KPT 10000
Serial No. – *****
(Attachment C, – Photograph 4)
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5.1.4 Micro-Processor
Manufacturer – Compuload
Model – N1440
Serial No. – ********
(Attachment C, – Photograph 5)
5.1.5 Micro-Printer
Manufacturer – Compuload
Model – 4060
No serial number found
5.2 Observations
5.2.1 The Wheeled Front-End Loader was used by Battle River Transit Mix to load
aggregate and other product for customers and the business. The Compuload
weighing system would calculate the weight of the product in the bucket of the
Wheeled Front–End Loader and then this could be printed out as a receipt or the
information was stored in the Micro-Processor.
5.2.2 The Transducer 1 was installed on the hydraulic system that operates the lifting
mechanism for the bucket on the Wheeled Front-End Loader. The Transducer
calculates the speed and differential in hydraulic pressure (compared to an empty
bucket) of the Wheeled Front-End Loader when it is lifting a bucket full of material.
This calculation is changed into an electronic signal that is sent by wire to the Micro-
Processor located in the operator’s cab of the Wheeled Front-End Loader. The
Micro-Processor gives a digital reading of the weight of the material in the bucket of
the Wheeled Front-End Loader. This digital reading can be printed off on the Micro-
Printer located just below the Micro-Processor. (Attachment C, Photograph 5)
5.2.3 At the time of the Alberta Occupational Health and Safety (OHS) investigation, the
Transducer 1 had been removed and was found lying on the right side front axle of
the Wheeled Front-End Loader. The Transducer 2 was found in the bucket of oil that
had been draining from the hydraulic system of the Wheeled Front-End Loader.
(Attachment C, Photograph 6)
SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT
6.1 The Compuload electronic weighing system was installed on the Wheeled Front-End
Loader approximately 3.5 years prior to the date of the incident. The date on the back
of the Micro-Processor indicates a testing date of October 30, 2008.
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6.2 In early June 2012, the Battle River Transit Mix’s Owner (************)
determined that the Compuload weighing system on the Wheeled Front-End Loader
was not functioning properly. The Owner (************) called Alberta Laser and
Tech Services Ltd. to visit his business and service the electronic weighing system.
6.3 On June 15, 2012 the Alberta Laser and Tech Services Ltd. Technician (*******
*****) and the Salesman (*************) arrived at the Battle River Transit Mix
shop just prior to the noon hour. They met with the owner of the Battle River Transit
Mix business (************). The Wheeled Front-End Loader was brought into the
shop. The Technician (************) requested a screwdriver from the Owner
(************) for taking off the front cover to access the Wheeled Front-End
Loader’s hydraulic system where the Transducer 1 was located. (Attachment C,
Photograph 7)
6.4 Both the Salesman (*************) and the Technician (************) knew how
to operate the Wheeled Front-End Loader, so the Owner (************) left for
downtown Wainwright to pick up some parts for his business and have lunch. There
were no other workers in the shop as most had been sent home due to a rainstorm
having occurred in the morning, stopping concrete pouring operations.
6.5 The Technician (************) proceeded to install a new Transducer 2 onto the
hydraulic system of the loader from underneath the Wheeled Front-End Loader with
the bucket down. The old Transducer 1 was set on top of the right hand front axle.
The new Transducer 2 was tested by moving the bucket up and it was determined that
the new Transducer 2 was giving incorrect readings. The Salesman (*******
********), who was watching the troubleshooting process, indicated that the
Technician (************) moved the bucket up about two thirds of the total height
distance possible. He then positioned himself under the bucket at the front opening of
the Wheeled Front-End Loader’s frame. (Attachment C, Photograph 8) The
Technician (************) intended to loosen the Transducer 2 and drain some
fluid, as he assumed there was an air bubble in the hydraulic fluid.
6.6 The Technician (************) loosened the Transducer 2 from the opening at the
front of the Wheeled Front-End Loader and the Transducer 2 inadvertently detached
from the anchor point in the hydraulic system. This started the Wheeled Front-End
Loader’s bucket to fall as the hydraulic fluid drained out onto the floor. The
Salesman (*************) warned the Technician (************) to leave this
location as the Wheeled Front-End Loader’s bucket was falling. The Technician
(************) stayed under the Wheeled Front-End Loader’s bucket and tried to
re-assemble the Transducer 2 onto the hydraulic system.
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6.7 At approximately 1:30 p.m. the Technician (************) was caught and crushed
between the Wheeled Front-End Loader’s frame and the lifting arm mechanism of the
bucket as it lowered to the ground due to the loss of hydraulic pressure.
6.8 A customer that had entered the shop called for emergency services.
6.9 The Salesman (**************) rushed to the Wheeled Front-End Loader’s
controls, started it, and tried to raise the bucket. It would not lift up as all the
hydraulic fluid had drained out and the hydraulic system was now open due to the
Transducer 2 not being attached.
6.10 Emergency Services personnel from Wainwright came and raised the bucket with
mechanical equipment and freed the Technician (************). (Attachment C,
Photograph 2)
6.11 The Technician (************) was pronounced dead at the scene by the local
Coroner.
SECTION 7.0 ANALYSIS
7.1 Direct Cause
7.1.1 The Technician (************) was fatally injured when he did not immediately
leave a position under a raised Wheeled Front-End Loader’s bucket when it started to
unexpectedly lower. He was caught and crushed between the bucket’s raising
mechanism and the framework of the Wheeled Front-End Loader.
7.2 Contributing Factors
7.2.1 This Volvo model of Wheeled Front-End Loader did not have available a
manufactured system of locking or securing the loader’s bucket in the raised position
to prevent it from inadvertently lowering. The Operator’s Manual for the Wheeled
Front-End Loader did reference “Safety When Servicing” by saying on page 150 of
the manual, “If service work has to be done under a raised blade or attachment, make
sure that it is secured before starting any work.” The Alberta Laser and Tech Service
Ltd’s workers did not reference the Operator’s Manual for the machine.
7.2.2 The Alberta Laser and Tech Services Ltd’s workers had not been conducting formal
hazard assessments for tasks they were completing on heavy equipment. Working
under a raised and unsecured Wheeled Front-End Loader’s bucket was a hazard. The
Technician (************) had done this many times without conducting a hazard
assessment and had become complacent to the hazard. No control measures had been
initiated for the contingency of hydraulic failure.
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7.2.3 The Alberta Laser and Tech Service Ltd’s workers did not support the raised arm of
the Wheeled Front-End Loader before entering this area to work.
7.2.4 The Wheeled Front-End Loader’s bucket was in a position curled up at the time of the
incident. If it had been in a position curled down, the lifting mechanism would not
have come all the way down, as the front edge the bucket would have stopped the
lifting arm mechanism from lowering all the way. (Attachment C, Photographs 2, 9)
7.2.5 The Transducer 2 could have been loosened from underneath the Wheeled Front-End
Loader instead of working under the raised bucket. (Attachment C, Photograph 10,
11)
7.2.6 The Hydraulic system where the Transducer 2 was attached, was in an awkward
location, and could not easily be seen or reached from the front opening in the
Wheeled Front-End Loader’s framework. This contributed to the Technician’s
(************) not being able to know how far he had loosened the threads holding
the Transducer 2 to the hydraulic system attachment point. (Attachment C,
Photograph 8)
SECTION 8.0 FOLLOW-UP/ ACTION TAKEN
8.1 Alberta Human Services; Occupational Health and Safety (OHS)
8.1.1 On June 15, 2012 Alberta OHS Investigators visited the site of the incident and
investigated the circumstances of the incident.
8.1.2 The following orders were issued to Alberta Laser and Tech Services Ltd.:
- A Stop Work Order was issued for the type of servicing that lead to the fatal
incident. Alberta Laser and Tech Services Ltd. were required to initiate hazard
assessment, elimination and control measures within their company. (According
to the OHS Code, Section 7)
- An order was issued for the company to develop a method of managing the
control of hazardous energy or rendering machinery inoperative or securing
moving parts before servicing is to take place. (According to the OHS Code,
Section 212)
- An order was written to the company to initiate the prevention of dangerous
movement of any powered mobile equipment that their staff would be servicing.
(According to the OHS Code, Section 258)
- An order was written to the company to implement the blocking of elevated parts
of machinery that is to be serviced. (According to the OHS Code, Section 261)
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8.1.3 The following orders were written to Battle River Transit Mix:
- The company was ordered to reply as to how, as a prime contractor, or contractor
hiring the services of another employer, they would ensure that the employer
hired would comply with the OHS Act, Regulation and Code.
- The company was required to ensure they had a copy of the OHS Act, Regulation
and Code available at the Battle River Transit Mix Plant site.
- The company was required to investigate the incident and develop a report
outlining the circumstances of the incident and the corrective measures to prevent
a similar incident.
8.1.4 An Alberta OHS Investigator visited a local Volvo Construction Equipment North
America Inc’s (Volvo) heavy equipment dealership to determine what measures the
dealership had for securing the lifting arm mechanisms of Wheeled Front-End
Loaders if they were being serviced. The newer Wheeled Front-End Loader
machines as well, did not have a built-in support mechanism. The dealership
personnel did indicate that the Volvo factory had designed a support mechanism for
servicing Wheeled Front-End Loaders with the lifting arm mechanism in a raised
position. The Alberta OHS Investigator communicated with Volvo head office to
obtain the design of this mechanism.
8.2 Industry
8.2.1 Alberta Laser and Tech Services Ltd. complied with the orders that were written by
the OHS Investigators.
8.2.2 Battle River Transit Mix complied with the orders that were written by the OHS
Investigators.
8.2.3 Volvo Construction Equipment North America Inc. supplied a newly released
document entitled, “Service Information, Working under raised boom”. (Attachment
B, Service Document)
8.3 Additional Measures
8.3.1 The OHS Investigator shared the “Service Information” document with Alberta Laser
and Tech Services Ltd. and with Battle River Transit Mix businesses.
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SECTION 9.0 SIGNATURES
ORIGINAL SIGNED August 31, 2012
Lead Investigator Date
ORIGINAL SIGNED September 11, 2012
Investigator Date
ORIGINAL SIGNED September 11, 2012
Manager Date
ORIGINAL SIGNED September 12, 2012
Regional Director, Central Date
SECTION 10.0 ATTACHMENTS:
Attachment A Map
Attachment B Service Document
Attachment C Photographs
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Attachment “C” Photographs
Page 1 of 11
Mechanic’s Creeper
Photograph #1 Shows the Wheeled Front-End Loader parked inside the Battle River
Transit Mix Shop in Wainwright. The floor-dry material had been applied
to soak up the spilled oil from the loader’s hoisting system prior to the
OHS Investigators’ arrival. There were a number of mechanic’s creepers
available for use for accessing the undercarriage of the loader. One is seen
on the floor between the right-side front and rear tires of the loader.
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Attachment “C” Photographs
Page 2 of 11
This is the hoisting mechanism used by These were the blocks installed by
emergency responders to lift the bucket emergency responders to secure the
with the center chain block and tackle bucket and extricate the Technician
Photograph #2 Shows a view of the front (bucket) of the Wheeled Front-End Loader in
the Battle River Transit Mix shop, looking towards the door of the shop
in a southerly direction. The bucket of the Wheeled Front-End Loader is
curled up and raised up on the blocks that were installed by Emergency
Services personnel when freeing the Technician who had been pinned
behind the bucket. With the bucket curled back, in this manner, it
allowed the lifting arm mechanism to fold right back against the front
frame of the Wheeled Front-End Loader.
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Attachment “C” Photographs
Page 3 of 11
Top of the This is the right-side hydraulic Transducer 1 sitting
loader’s front ram/piston that raises the Wheeled on the top of the axle
right-side Front-End Loader’s bucket. It is up
wheel very slightly due to the bucket being
up on blocks installed by Emergency
Responders.
Photograph #3 Shows where the Transducer 1 was discovered. Transducer 1 is located
on the top of the right-side front axle of the Wheeled Front-End Loader.
This view is taken looking straight down from the top of the right side
front tire onto the axle. Transducer 1 was set aside while the Technician
was installing and testing Transducer 2. See Photograph 7.
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Attachment “C” Photographs
Page 4 of 11
Photograph #4 Shows Transducer 2 which was found in a rubber oil drain pan under the
Wheeled Front-End Loader. See Photograph 6.
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Attachment “C” Photographs
Page 5 of 11
Micro-Processor
Micro-Printer
with digital read-out
below the Micro-
screen
Processor
Photograph #5 Shows the inside of the operator’s cab in the Wheeled Front-End Loader.
To the right of the steering wheel is mounted the Micro-Processor and the
Micro-Printer that are part of the Compuload electronic weighing system.
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Attachment “C” Photographs
Page 6 of 11
Photograph #6 Shows the rubber oil drain pan that was under the Wheeled Front-End
Loader at the time of the incident. The Transducer 2 was found in the
hydraulic oil that was in the pan. It had come off its location on the
hydraulic system when the Technician tried to loosen it to release a
suspected air bubble in the hydraulic system. See Photographs 10, 11.
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Attachment “C” Photographs
Page 7 of 11
Shows how the hydraulic lift The Technician had removed
Transducer 1 was arm rams/pistons have been the cover over this hole in the
found on the axle extended with the loader’s front frame of the loader and
behind the loader’s bucket curled down leaving was attempting to service the
frame in this room to work somewhat hydraulic system through this
location. safely. opening.
Photograph # 7 Shows the area where the Technician was standing/working. The
opening in the centre of the front frame was where the cover was
removed to access the hydraulic system. Notice how much room
there is to work in this view as the lift arms have been raised and the
Wheeled Front-End Loader’s bucket has been curled down and rested
on the floor as a safety precaution. See Photograph 9.
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Attachment “C” Photographs
Page 8 of 11
The Technician would have had to reach in behind this area to loosen the
Transducer 2. See the following photographs to understand the difficulty of
this task from this work position.
Photograph #8 Shows from a different angle, the Wheeled Front-End Loader’s front
frame opening, to orient the viewer to where the Transducer 2 was
located. From this work position it would be very difficult to determine
how much the Transducer 2 was being loosened.
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Attachment “C” Photographs
Page 9 of 11
This is the lift arm mechanism that
raises and lowers the Wheeled Front
End Loader’s bucket
Photograph #9 Shows how the Wheeled Front-End Loader’s bucket could be positioned
to keep the lift arm mechanism from collapsing. Ideally a support for the
lift arm mechanism should be used. This support system has been
designed by the manufacturer as indicated by Attachment B, diagrams.
The bucket could also be curled further down so the front edge of the
bucket would be perpendicular. This would raise the lift arm mechanism
even higher adding more room to work in the space at the front of the
loader.
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Attachment “C” Photographs
Page 10 of 11
Transducer 2 had been threaded into this coupling prior to the
Technician trying to loosen it partially. See the next photograph.
Photograph #10 Shows the location where the Transducer 2 had been attached to the
hydraulic system of the Wheeled Front-End Loader. This view is taken
from under the loader looking up into the location identified in Photograph
8. This work area would have been the safest location for servicing the
Transducer 2. This attachment location was surrounded by hydraulic hoses
which illustrates how difficult the servicing would be from the exterior of
the Wheeled Front-End Loader.
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Attachment “C” Photographs
Page 11 of 11
Photograph #11 Shows how the Transducer 2 was assembled prior to the Technician
trying to loosen it for bleeding any air in the hydraulic system.
Hydraulic hoses had to be forcefully moved aside to gain access to the
Transducer 2 when it was assembled onto the system.
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