The employee, a 43-year-old temporary worker who was operating a tower conveyor at a lumber planing mill, was clearing a lumber jam when he missed his footing at the end of a catwalk and fell 17 feet to the concrete floor below. The fall occurred on June 23, 2005, and the worker died 2 days later from blunt head and chest injuries.

According to the FACE report, the unguarded, narrow walkway – which was one of five 12-inch-wide catwalks that provide access to the interior of the tower conveyer system – was "the primary risk factor." Exacerbating the risk, the report says, was the presence of a 2-foot gap between each catwalk and the metal stairway on the side of the tower.

Citing Oregon OSHA 29 CFR 1910.23(c), the report points out that "[g]uardrails are required on all open sides of any regularly used access walkway that is situated 4 feet or more above the adjacent floor or ground level."

"In this incident, the catwalks were only 12 inches wide and the installation of guardrails was not feasible through the interior crossbeams of the machine," the report explains. "The employer has since modified the stairway and landings to allow better access to the catwalks, and has installed wire cables along the length of each catwalk as part of a new tower fall protection system."

Additionally, the report says, workers accessing the catwalks now are provided and required to wear a body harness with a lanyard attached to the cable.

Temporary Workers Must Receive Safety Training

The FACE report notes that the fatality was the first in the 51-year history of the sawmill company – which operates a planing mill, stud mill, sawmill, timber company and lumber wholesale company – and the company's first planer tower injury in 30 years.

According to the FACE report, the sawmill company had a number of safety measures in place, including a comprehensive, written safety program; a safety committee comprised of members of labor and management; regular safety meetings; job-safety analyses for critical jobs; and safety training, which was provided by mill supervisors.

However, the report adds that "[t]emporary workers were provided on-the-job training but were not included in the formal safety training program."

"A temporary labor contractor, as illustrated in this incident, is responsible for general employee competence and orientation," the report says. "The direct employer of a temporary worker is responsible for specific job training and safety."

The report adds that the sawmill company "now provides the same safety training received by regular employees to temporary employees."

Thorough Hazard Surveys Recommended

Another area of concern for Oregon FACE investigators was the thoroughness of the job-safety analyses being conducted at the lumber planing mill.

The report points out that the job-safety analysis for the tower operator's job identified noise and hand, foot and eye injuries as potential hazards. While tower operators were required to wear PPE such as safety glasses and leather gloves, "[t]he potential for falls was not identified in the safety analysis and tower operators were not provided fall protection."

Oregon FACE investigators recommend conducting thorough hazard surveys and job-safety analyses to identify hazards and unsafe work practices.

"A hazard survey is best performed regularly by a competent person, such as the safety manager," the report says. "Corrective actions should be set with a schedule for completion."

Job-safety analyses identify safe work procedures and necessary PPE for each step of the work process.

"Employee training should incorporate the results of the job-safety analysis," the report concludes.