Worker was not trained to perform the task; no training was required to perform the task, but he died nonetheless

Another worker killed, and his colleagues injured, due to, what appears to be, a combination of an inherently unsafe hydraulic system, and the lack of training. What surprises me is, how many more deaths and injuries will need to occur before state and federal agencies wake up to the fact that less that over 95% of the people that work on and around hydraulic systems are properly trained, and that more than 99% of the hydraulic systems operating in mills and factories throughout the US are inherently unsafe by design, from the point of view of stored energy.

I suggest you read the newspaper article below so you can understand why I am frustrated.

http://www.oregonlive.com/washingtoncounty/index.ssf/2011/10/stimson_lumber_fined_5000_for.html

The regrettable, and completely avoidable, accident that occurred at the Stimson Lumber Mill is just another example of just how out of touch State and Federal safety agencies are when it comes to matters relating to hydraulic safety. From all accounts the victim and his colleagues were working on a hydraulic system that was equipped with one, or more, hydro-pneumatic accumulators (energy storage devices).

Hydro-pneumatic accumulators are known to trained mechanics as energy storage devices. However, in the hands of untrained personnel, they are nothing more and nothing less than “bombs.”

From all accounts, the victim and his colleagues could not determine if the hydraulic system contained stored energy, which seems to be what caused the accident. 

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The fact is, over 99% of the hydraulic system operating in mills throughout Oregon, and every other state in the nation, are inherently unsafe from the point of view of stored hydraulic energy. The hydraulic system that the victim and his colleagues were working on was, in my opinion, unsafe from its inception.  It was only a matter of time before it either killed, or seriously injured, one or more people.

OSHA mandates that companies have an energy control program, and that companies train their people on energy control procedures. However, OSHA, hydraulic system designers, and corporate safety managers, ignore the fact that hydraulic systems DO NOT comply with OSHA’s standards with regard to the controlled release of stored hydraulic energy.

The standard requires workers to isolate a machine’s power source (lockout and tagout) before performing work on the machine. However, hydraulic systems have the inherent ability to store energy after the power source is locked out and tagged. What workers cannot do is determine if a hydraulic system contains stored energy, and even they could, it is not possible for them to safely remove it. What they are forced to do, as it seems they did in this case, is fly by the seat of their pants, and hope and pray they live to see another day.

The fact that both state and federal agencies, and companies like Stimson Lumber permit people that have little or no training in hydraulics to perform service and repair work on hydraulic systems, doesn’t help the matter. Telling an untrained mechanic to work on hydraulic systems is irresponsible enough. Giving an untrained worker an order to work on a hydraulic system, which is unsafe by design, is ludicrous. 

From all accounts, it was only a matter of time before a Stimson worker was either killed, or seriously injured while working on the company's hydraulic systems. Working on and around a hydro-pneumatic accumulators without proper training is akin to diffusing a bomb. Things can get very ugly very quickly.

From all accounts the hydraulic system Mr. Allen and his colleagues were working on was inherently unsafe by design (like the other 99% of the hydraulic systems operating in the US). It is also evident that Mr. Allen, and his colleagues did not have the critical training needed to identify the potential hazard, or perform the task safely. Ironically, companies, like Stimson, are not bound by law to insure workers are trained in hydraulic safety, or fundamental hydraulics. 

Most companies will only spend money on worker safety if it’s required by law, which means that over 98% of the millworkers working in Oregon have never received hydraulic safety training, and only about 20%, if that, can pass a hydraulic competency test. Accordingly, there will be more accidents, and there is no doubt, there will be more injuries and deaths. Sadly, the conclusions will remain the same: "worker was not trained to perform the task; no training was required to perform the task."

I sincerely hope that Mr. Allen’s family was able to sue the company that designed the hydraulic system. I would be interested to know if the Oregon Occupational and Health Safety Administration cited the machine manufacturer for delivering to Stimson a machine that I am alleging was inherently unsafe by design.

I was astounded by the comments made by Ms. Debra Muchow, Stimson’s Vice-President, regarding Mr. Allen: “We'll never know from the employee's perspective if he was not trained properly or whether it was just a matter of a mistake at that time.” How disgraceful!

It seems Stimson must be a very unsafe place to work. Judging from Ms. Muchow’s comments, the company doesn’t seem to know the background, qualifications and training of its employees. Her comments also reflect poorly on the company’s supervisors. Surely Mr. Allen’s supervisor must have been aware of his work skills. How would it have been possible to give him work assignments that Mr. Allen could perform with any degree of safety if his supervisor, and the company's vice president, did not know his qualifications?

The Oregon Occupational and Health Safety Administration’s response to the accident doesn't surprise me at all. It’s the usual “victim was not properly trained” scenario. Moreover, there was no mention of the fact the hydraulic system was, in my opinion, inherently unsafe by design. Regrettably, the Oregon Occupational and Health Safety Administration will probably do nothing to make it mandatory for ALL workers that perform work on and around hydraulic system receive proper training. They will also probably ignore the fact that more than 99% of the hydraulic system operating in Oregon (not just in the lumber mills) do not have the means to permit workers to determine if a hydraulic system contains stored energy, or the means to safely remove it is it does.

What we can learn from Mr. Allen’s regrettable, and avoidable, accident:

Mechanics:

1. To prevent the vice president of your company, and your supervisor, from being confused about your knowledge and training, arrange a meeting with your company’s human resources officer, and your supervisor. Have them put on record your qualifications and training. Also, make them aware of any work you do that you are not trained or qualified to do.

2. OSHA’s lockout/tagout standard clearly states: “Energy sources including electrical, mechanical, hydraulic, pneumatic, chemical, thermal or other sources in machines and equipment can be hazardous to workers. During the servicing and maintenance of machines and equipment, the unexpected startup or release of stored energy could cause injury to employees.” 

Lockout and tagout does not guarantee a hydraulic system is safe to work on. Most hydraulic systems have the inherent ability to store energy after shutdown. OSHA states, “the release of stored energy must be controlled.” Unfortunately, this is not possible to achieve on more than 99% of hydraulic systems operating in the US.

The only way for a worker to remove stored energy from a hydraulic system is to ignore both the OSHA’s standard, and the machine manufacturer’s warnings, and discharge the stored energy to atmosphere with absolutely no way to control it.

3. OSHA, US companies, and your company's safety managers do not recognize hydraulics as an occupational hazard. If they did, people that work on hydraulic systems would have the same worker rights and privileges as electricians.

In OSHA’s defense, the agency is as naive about matters related to hydraulic safety as the engineers that design hydraulic systems. It's a simple case of the blind leading the blind!

Engineers:

If you are a hydraulic system designer, even though there are no standards covering the safe release of stored hydraulic energy, make sure the systems you design are safe. Mr. Allen may have been alive today, if he had had the means at his disposal to determine if the system he was working on contained stored energy.

Safety personnel:

1. If your company does not currently provide hydraulic safety training for the people that work on and around hydraulic systems, make it your top priority to get them the training they desperately need. Bear in mind, most workers cannot recognize potential hazards because they don't have training in fundamental hydraulics to do so.

2. The fact that OSHA ignores hydraulic safety doesn't mean that hydraulic systems are safe. On the contrary, hydraulic systems are arguably more hazardous than electrical systems.

3. If you teach your employees lockout and tagout. Don’t just talk the talk, please walk the walk. See to it that the hydraulic systems in your company can be safely de-energized after LOTO is performed.

Supervisors:

1. You "borrowed" the people that report to you from their respective families. Your primary responsibility to workers and their families, is to insure that you take care of them while they are in your care, and that you return them to their respective families in the same, or better, condition than they were when you "borrowed" them. If Mr. Allen's supervisor had fulfilled his promise to his family, he would never have been killed at work. NEVER permit a person perform work on any machine/system unless you are completely satisfied they have the training to perform the work safely.

2. Like electrical, confined space, hazardous materials, etc., workers that work on and around hydraulic systems MUST receive training in hydraulic safety. 

3. Look for the best training for your workers, and don't abbreviate the training. Avoid using your suppliers’ sales personnel to train your workers unless they are competent. They may be qualified salespersons, but they are not necessarily educators. Your workers deserve the best training possible. Workers must empowered to think safety and work safely. Besides, properly trained workers will increase productivity, and decrease downtime. It's a win-win for the worker, you, and the company.

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A motion-less actuator does not confirm a hydraulic system is energy-less

I received a call from the owner of a fleet of refuse trucks.

He called me because he had concerns about the safety of his mechanics as it relates to the hydraulic systems on his fleet of refuse trucks. 

Here is an overview of our discussion:

The truck’s trash compactors are powered by hydraulic systems. His mechanics have to get inside the compactors to perform cleanup, maintenance and repair work. They also have to perform service and repair work on the vehicle's hydraulic systems. He felt that the safety instructions in the vehicle's service manual about making it safe for workers to work inside the compactor, or work on the hydraulic system, were vague. He apparently decided to call the manufacturer to get clarification on the issue. The manufacturers' representative, with whom he discussed the issue, advised him to have the company’s workers follow the steps provided in the vehicle's service manual, which are:

1. Shut off the engine.

2. Activate the compactor's control valve moving it back-and-forth while observing the compactor. If the compactor does not respond (move) while the control valve is being shifted back-and-forth, it is safe for a worker to enter the compactor.

3. If the compactor does respond (move) when the control valve is being shifted back-and-forth continue operating the control valve until the compactor stops moving. When it no longer moves when the control valve is shifted back and forth, it is safe for a worker to enter the compactor.

He asked the manufacturer's representative if there was a possibility there could be stored energy in the hydraulic system even though the compactor does not move when shifting the control valve back-and-forth. He said he had no reason to believe this could happen. He also mentioned the company had no record of any incidents related to his concerns. He asked if there was any way workers could confirm, beyond the fact the compactor did not move, if there is stored energy in the hydraulic system. He said no, and added that he "didn't think it was necessary."

The owner added that he was concerned that the hydraulic system could possibly have stored energy despite the fact that the engine was shut off, and workers had followed the safety recommendations in the vehicle's service manual. 

One of the statements made by the refuse truck manufacturer’s representative when asked by the truck owner if there is a possibility there could be stored energy in the hydraulic system even though the compactor no longer moved when shifting the control back and forth is particularly disturbing. He answered that he had “no reason to believe this could happen” without offering advice as to making certain it could not move.

     

I told the refuse truck owner that he had good reason to be concerned. I advised him that although a hydraulic actuator (cylinder or motor) does not respond when the control valve is activated, DOES NOT mean a hydraulic system does not contain stored energy, nor does it mean the actuator will not move unexpectedly, for the following reasons:

1. An actuator will not move below a certain pressure threshold because there is not enough force to overcome the load.  

2. There could be debris in slides, rollers, and/or concealed areas, which can prevent the compactor from moving. When a mechanic moves it may lurch forwards/backwards.

3. Compactor out of alignment, which causes it to bind.

4. Control valve is pilot-operated, which means it only functions when the pump is operating.

5. Wiring problem with a solenoid controlled control valve, which prevents it from shifting the valve.

6. Control valve seized: hydraulic system remains energized even though compactor remains stationary when valve is activated.

7. Control cable broken but break not visible.

8. Untrained person shifts the incorrect control valve.

9. Debris causes sliding mechanism to jam. Prevents compactor from moving when valve is activated, and does not release the stored hydraulic energy.

10. Pressure low due to internal wear. Sufficient pressure to cause injury, but not sufficient to move compactor.

11. Cylinder port relief valve malfunction: will not move cylinder in one direction, but cannot move in the opposite direction because rod is fully extended or retracted.

12. The actuator is equipped with load holding valves, i.e. counterbalance or pilot-operated check valves. Will not permit actuator to move if pump is shut off.

Regrettably, the same rules that apply to electrical safety do not apply to hydraulic safety even though, in this instance, the situation is, for all intents and purposes, identical. For example, if an electrician turns a light switch on and the light fails to illuminate, the electrician does not have to rely on guesswork to determine if the circuit is “dead.” A simple check with a voltmeter will confirm the situation. Regrettably, even though the hydraulic industry has the instruments needed to confirm whether or not a hydraulic system stores energy after shutdown, machinery and equipment designers typically don’t design them into hydraulic systems because it adds cost. Needless to say, OSHA ignores the problem.

When it comes to hydraulic systems don’t look to OSHA for help:

Regrettably, even though by law, workers must undergo energy control training (OSHA's lockout/tagout training), which includes information about the safe release of stored hydraulic energy, and protecting workers from the unexpected movement of equipment, OSHA ignores the fact that over 99% of the hydraulic systems operating in the USA do not have the means to either verify if a hydraulic system contains stored energy, or to safely remove/release it if a system does contain stored energy. Moreover, OSHA does not hold machinery and equipment manufacturers accountable for designing hydraulic systems, which are inherently unsafe by design from the point of view of stored hydraulic energy.

Hydraulic systems are particularly hazardous when it comes to stored energy, because, unlike electrical systems, where if a breaker is isolated the entire circuit is de-energized, a hydraulic system, depending on its magnitude and complexity, can store energy in numerous "zones," or "pockets." Therefore to make a hydraulic system safe to work on, a worker has to know where every potential energy "zone" is, and has to be able to safely remove the stored energy from each zone.

Here is my advice regarding this matter:

Get it in writing: If the refuse truck manufacturer, or any machine manufacturer for that matter, is confident that the safety procedures in the vehicle’s service manual are fail-safe, i.e., guarantees, without a shadow of a doubt, that if a worker follows the safety instructions provided in the service manual with respect to working inside the compactor, and performing service, repair, and maintenance work on the vehicle’s hydraulic system, they will have no problem with setting your mind at ease by giving it to you in writing.

The document must be formalized on the company’s letterhead, and signed by the company’s safety manager, and engineer. I further advise you to discuss with the manufacturer the need to install some type of mechanism that prevents the compactor from unexpectedly moving while a worker is performing work on same. Also, I highly recommend you refrain from allowing a worker to perform invasive work on the vehicle’s hydraulic system until such time as the manufacturer has assured you the hydraulic system is completely free of stored energy after following the recommended pre-work safety procedures.

Warning:

This general warning should be posted on ALL hydraulic systems:

WARNING: Performing a lockout/tagout in accordance with OSHA’s lockout and tagout protocols DOES NOT make a hydraulic system safe to work on. If, after isolating the power supply, a hydraulic actuator (cylinder or motor) does not respond when the directional control valve is activated, IT DOES NOT CONFIRM the hydraulic system cannot operate. You MUST verify if there is stored energy in the hydraulic system, and if there is, you must remove it safely. Also, a hydraulic system can store energy in numerous places. You MUST insure ALL “pockets” of stored energy are isolated.

Failure to follow this warning could cause an accident that can lead to severe injury, death, and/or severe property damage.

Have a question about a hydraulic safety matter, I will be happy to give you my opinion?

NOTE: I will never use your name or your company’s name in my response.

OSHA "talks the talk" when it comes to stored hydraulic energy, but continues to ignore the "elephant in the room."

Here is a report of yet another mechanic that suffered a debilitating oil injection injury but, as usual, the mechanic, not the machine designer, shoulders the blame:

http://www.timberlinemag.com/articledatabase/view.asp?articleID=4167

Here are the ridiculous, and unrealistic, statements under sub-heading “Recommendations.”

“At the time of the repair, the mechanic had not consulted the specific manual for this machine to determine the proper procedure to dissipate oil pressure throughout the system.”

FACT: There were no procedures in the manual for dissipating oil pressure in the system.

“During the accident investigation, the manual still could not be located. As increased technology has complicated shut-down procedures (the addition of hydraulic accumulators for example), no assumptions can be made, and a generic shut-down procedure should not be trusted.”

FACT: There is no such a thing as a “generic shutdown procedure” for a hydraulic system.

“Machine-specific owners’ manuals should be readily available and consulted prior to undertaking repairs.”

FACT: Machine specific owners’ manuals DO NOT provide information about how to determine if, after shutdown, a hydraulic system contains stored energy. Moreover, even if a person could determine if a hydraulic system contains a lethal amount of stored energy, there is no safe way to remove it.

“When searching for hydraulic leaks and servicing charged systems, heavy gloves will provide additional protection for the hands.”

FACT: There are no gloves currently available that will protect a worker from an oil injection injury.

This accident epitomizes the disparity between OSHA's standard (Control of Hazardous Energy (Lockout/Tagout) (29 CFR 1910.147), and the reality of the situation.

Here are a few excerpts from OSHA’s Control of Hazardous Energy (Lockout/Tagout) 29 CFR 1910.147:

• This standard covers the servicing and maintenance of machines and equipment in which the unexpected energization or start up of the machines or equipment, or release of stored energy, could harm employees. This standard establishes minimum performance requirements for the control of such hazardous energy.

FACT: Less than 1% of the hydraulic systems operating in the USA meet the minimum performance requirements for the control of hydraulic energy.

• This standard applies to the control of energy during servicing and/or maintenance of machines and equipment.

FACT: The standard may apply to other forms of energy, but it in no way, shape, or form applies to hydraulic energy.

• Energy control program. The employer shall establish a program consisting of energy control procedures, employee training and periodic inspections to ensure that before any employee performs any servicing or maintenance on a machine or equipment where the unexpected energizing, startup or release of stored energy could occur and cause injury, the machine or equipment shall be isolated from the energy source and rendered inoperative.

FACT: Not only do ALL employers fail to establish a program consisting of energy control procedures for hydraulic systems, they couldn’t even if they wanted to, because hydraulic systems are not designed to facilitate the controlled release of stored energy.

• How do I know if the OSHA standard applies to me?

If your employees service or maintain machines where the unexpected startup, energization, or the release of stored energy could cause injury, the standard likely applies to you.

FACT: The standard does apply to you if you work on hydraulic systems. As you can see from this accident, you and your colleagues are highly susceptible to this type of accident because both your employer, and OSHA, ignore the problem.

• The standard applies to all sources of energy, including, but not limited to: mechanical, electrical, hydraulic, pneumatic, chemical, and thermal energy.

FACT: While OSHA’s Control of Hazardous Energy (Lockout/Tagout) 29 CFR 1910.147 applies to all sources of energy, including hydraulic energy, both your employer, and OSHA, ignore the fact that less then 1% of the hydraulic systems operating in the USA, Canada, Australia, Europe, et al, can be de-energized after shut down.

My recommendation: NEVER loosen a hydraulic connector, or remove a hydraulic component, unless you can verify if the hydraulic system you are working on contains stored energy. In all likelihood it does, and there is no safe way to remove it.

Since your employer and OSHA ignore the problem, the only thing left for you to do, is to refuse to work on a hydraulic system if you have any doubt that it contains stored energy.

Here is a video of an accident I filmed while conducting a hydraulic cylinder performance test:

https://www.youtube.com/watch?v=1VYqoTpv5EU

The accident is identical to subject accident in which the victim suffered an oil injection injury.  The victim in this accident performed the identical procedure described in the subject accident. As you can see from the video, the victim was fortunate in that the explosion was deflected toward the machine’s cab.

Post accident I installed a Safe-T-Bleed connector in the line, and repeated the procedure. The lowest pressure I could achieve after following the manufacturers‘ (Doosan) recommendations, was 500-PSI: a pressure well into the territory that could cause you to suffer a debilitating oil injection injury, and even cause you to lose your life.

The information in this blog applies to ALL industrial and mobile hydraulic systems - no exceptions! Before you work on any hydraulic system, read the respective manufacturers’ warnings about the consequences of discharging high-pressure hydraulic oil to atmosphere. Then, ask the respective manufacturer’s engineering department to write your company a letter stating that post shut down the entire hydraulic system on machine model XXXX de-energizes, and is thus completely safe to work on. Until you receive the letter, keep your hands, eyes and body away from hydraulic systems!

I share because I care.