The Kentucky Fatality Assessment and Control Evaluation (FACE) Program is tasked with investigating fatalities and making recommendations to ensure they do not occur again. This is one of their recent cases.
On Tuesday, March 17, 2020, a 44-year-old male farm employee (victim) was unloading corn from a large, 80,000-bushel grain bin via a bottom-mounted auger. During the course of the unloading process, the flow of corn seized due to bridged corn.
According to OSHA, “bridging’’ occurs when grain clumps together, because of moisture or mold, creating an empty space beneath the grain as it is released. Bridged grain resists the downward pull that normally moves loose grain to the bin outlet and rarely becomes hard enough to support a person” (OSHA, 2011). The farmworker entered the grain bin without utilizing fall protection and used a large PVC-pipe to push and spread the corn.
While doing so, the bridged corn unexpectedly collapsed. The victim fell and was engulfed by the corn as it began to flow again. A farm employee working on the exterior of the grain bin stated to authorities that he could no longer hear the victim inside the grain bin. The coworker climbed to the top of the grain bin to look for the victim, but could not see him due to the collapsed corn.
After the coworker descended from the top of the grain bin, he asked a farm employee to contact emergency services to advise that a farmworker had been involved in a grain bin engulfment. In addition to emergency services, a second co-worker at the farm also contacted several members of neighboring farms to assist with the rescue of the victim.
Emergency personnel arrived on scene approximately 30 minutes after receiving the call. Upon arrival, local volunteers from surrounding farms were prepared to cut an opening in the grain bin with a torch in an attempt to rescue the engulfed farm employee as quickly as possible. EMS and farm employees discussed the potential risk of fire and it was determined that cutting into the bin was not the best recovery option.
EMS worked together with local volunteers to free the victim for several hours by unloading the corn onto trucks. Once the majority of the corn had been unloaded, EMS utilized the Jaws of Life, a hydraulic cutting apparatus, to recover the victim. The recovery lasted nearly four hours and the body was freed at 2:43 p.m. Upon recovery, the victim was pronounced deceased at the scene by the local coroner, who ruled the cause of death as suffocation.
Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in the injury or fatality. Kentucky FACE investigators identified the following unrecognized hazards as key contributing factors in this incident:
- Lack of hazard recognition
- Failure to utilize fall protection
- No emergency action plan
Recommendation #1: Implement Job Hazard Analysis process
OSHA defines a job hazard analysis (JHA) as a technique that focuses on job tasks to identify hazards before they occur. It focuses on the relationship between the worker, the task, the tools, and the work environment. The agency states that ideally, after you identify uncontrolled hazards, you will take steps to eliminate or reduce them to an acceptable risk level (OSHA, 2002).
Had a JHA been previously performed, the employer would have likely observed the hazards associated with the task of entering a grain bin, including the need for an adequate body harness, rescue line and spotter. OSHA suggests a job hazard analysis be performed when completing the following types of jobs: jobs with the highest injury or illness rates; jobs with the potential to cause severe or disabling injuries or illness, even if there is no history of previous accidents; jobs in which one simple human error could lead to a severe accident or injury; jobs that are new to your operation or have undergone changes in processes and procedures; and jobs complex enough to require written instructions (OSHA, 2002). Companies should implement a job hazard analysis process to assess risk prior to performing work.
Recommendation #2: Employers should implement an emergency action plan
After learning of the incident, the involved company immediately called 911 and local farmers to assist. A local farmer arrived on scene shortly before emergency responders to cut the grain bin open with a cutting torch. EMS and farm employees discussed the potential risk of fire and it was determined that cutting into the bin was not the best recovery option due to potential risk for fire, a risk that had not previously been considered.
Having an emergency action plan in place can be instrumental when emergencies arise as it can eliminate confusion when emergencies occur, saving critical time. According to OSHA standard 1910.38, the employer must have an emergency action plan (EAP) whenever an OSHA standard requires one. Although the involved company acted quickly, a written emergency action plan for performing a rescue was not in place. Emergency action plan must be in writing, kept in the workplace, and available to employees for review.
Employers who are required to have an emergency action plan should take the necessary steps to implement an EAP and perform associated training in accordance with the applicable OSHA standard.
Recommendation #3: Employers should require employees to utilize adequate fall protection when entering a grain bin is necessary.
Discussion: Although fall protection harnesses were available, the victim was not utilizing fall protection when the incident occurred. According to OSHA standard 1910.28(b)(1)(i), Employer must ensure that each employee on a walking-working surface with an unprotected side or edge that is 4 ft. (1.2 m) or more above a lower level is protected from falling by one or more of the following: Guardrail systems; Safety net systems; or Personal fall protection systems, such as personal fall arrest, travel restraint, or positioning systems (OSHA, 2016).
Recommendation #4: Employers should train employees on the known hazards associated with grain bin entry.
In a study produced by Purdue University’s Agriculture Research Program, there were 1,201 documented incidents in grain storage facilities from 1964-2013. Of those incidents, 809 involved entrapment or engulfment of free-flowing grain. Engulfment cases involving corn specifically account for 47% of all grain bin fatalities, which make it the leading grain medium in recorded incidents (Freeman & Hulbert, 2015). According to OSHA, the grain handling industry is a high hazard industry where workers can be exposed to numerous serious and life-threatening hazards. These hazards include: fires and explosions from grain dust accumulation, suffocation from engulfment and entrapment in grain bins, falls from heights and crushing injuries and amputations from grain handling equipment; however, suffocation is a leading cause of death in grain storage bins. Suffocation can occur when a worker becomes buried (engulfed) by grain as they walk on moving grain or attempt to clear grain built up on the inside of a bin. Moving grain acts like "quicksand" and can bury a worker in seconds. "Bridged" grain and vertical piles of stored grain can also collapse unexpectedly if a worker stands on or near it. The behavior and weight of the grain make it extremely difficult for a worker to get out of it without assistance (Grain Handling. (n.d.).)