Board of Investigation (BOI) Report Contractor Fatality at ANP Site

23 September 2011

US Army Corps of Engineers

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Board of Investigation (BOI) Report Contractor Fatality ANP Site

BOI Members (Voting Members)

Edwin Cuebas (President) Charles Comeau (Member) Edwin Perdue (Member)

BOI Advisor (Non-voting members)

Patrick Freedman Technical

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Board of Investigation (BOI) Report Contractor Fatality ANP Site

Accident Information: Date: 23 September 2011 Location:XXXXXXXXX Prime Contractor:XXXXXXXXX Result: Worker killed while operating a concrete mixer Background: A concrete mixer operator was cleaning our his concrete mixer in preparation for lunch A worker near the mixer heard a noise and turned to find the mixer operator lying on the ground next to the concrete mixer with injuries to back Injured operator was transported to the District medical clinic where he later expired from his injuries
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Project Site Layout

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In the photo below, a worker demonstrates the position in which the injured operator was found relative the concrete mixer and the mixers loading chute.

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Board of Investigation (BOI) Report Contractor Fatality ANP Site

Direct Cause: The concrete mixers loading bin lowered rapidly striking the victim and knocking him to the ground. Indirect Causes: Lack of an effective safety program to include the lack of training on the proper operation of equipment such as the concrete mixer. Contributing Factors: Conducting concrete mixing operations with only one person created an environment more prone to accidents due to the lack of a buddy system. The operator became complacent due to the lack follow up safety meetings to remind the operator of the potential hazards while operating the equipment. Worksite was 65 miles from the nearest medical center.

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Board of Investigation (BOI) Report Contractor Fatality ANP Site

Recommendations:
Set up a formal training program for personnel operating and working around this type of concrete mixer. The program should as a minimum cover proper startup, operation, and shutdown of the concrete mixer as well as the potential hazards associated with the equipment. Develop a proper AHA for this activity and ensure that three phase inspections are properly conducted for the activity. Always have two personnel present during operation of the concrete mixer. USACE shall ensure Contractor is implementing an acceptable Accident Prevention Plan & is submitted for review & acceptance USACE shall ensure the job site is in compliance with the Safety & Health Requirements Manual (EM 385-1-1)

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Board of Investigation (BOI) Report Contractor Fatality ANP Site

Recommendations (cont.): USACE shall ensure the job site is in compliance with the Safety & Health Requirements Manual (EM 385-1-1) USACE shall periodically attend Contractors weekly toolbox meetings to ensure safety standards are being implemented properly USACE shall ensure all safety requirements are being maintained by the Contractor based on EM 385-1-1 USACE shall audit the Contractors safety training records

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Board of Investigation (BOI) Report Contractor Fatality ANP Site

Accident Prevention Items: Contractor shall address all recommendations in their Accident Prevention Plan (APP) and submitted for review and acceptance by date here USACE Safety Officer shall track APP progress to assure acceptance is done by date here USACE Project Engineer shall audit the Contractors employee training documents on date here

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Board of Investigation (BOI) Report Contractor Fatality ANP Site

The Board thanks the following for their support during the investigation:

Feyzabad Resident Office Mazar-e-Sharif Area Office Office of Counsel Safety Office

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Board of Investigation (BOI) Report Contractor Fatality ANP Site

Questions?

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