To paraphrase the Greek philosopher Heraclitus, the only constant at work is change, and workers often have to figure out new ways to do things in order to adapt. If that’s not done with safety in mind, however, it can lead to injury or even death.
For example, when a piece of equipment isn’t rated to perform a certain task but is used for that purpose anyway, the equipment could fail, as a recent National Transportation Safety Board (NTSB) investigation into a fatal railroad incident illustrates.
Specs indicated attachment was designed for 1 purpose only
On Sept. 22, 2021, a W.T. Byler Company contract equipment operator was working on the Union Pacific Railroad near Castroville, Texas.
The equipment operator was assisting Union Pacific workers with a timber replacement project on a railroad bridge, transporting steel grating panels from the bridge to a staging location less than a mile away.
He was using a Caterpillar mini hydraulic excavator that had been outfitted with retractable railroad wheels by Ballast Tools Equipment so that it could operate as a rail-mounted roadway maintenance machine (RMM). This RMM was equipped with a standard boom and stick for lifting materials over the front of the machine and had a lifting capacity rating of 6,549 pounds.
The load weighed 2,200 pounds and consisted of three steel grating panels, each 20 feet long by 3 feet wide.
A clamping work head attachment was selected for transporting these panels. However, the manufacturer’s specifications stated that this type of attachment was designed for use with single crossties. The specifications didn’t discuss any other uses for this attachment.
Load dropped, one panel smashed through windshield
A Union Pacific bridge supervisor later confirmed to NTSB investigators that he observed the equipment operator using the clamping work head attachment to grip the steel grating panels and transport the load. The load was suspended in front of the RMM with the panels oriented lengthwise above the centerline of the track.
A short time after observing the equipment operator using the RMM to move the panels, the bridge supervisor attempted to radio him but didn’t receive a response. The bridge supervisor and two other Union Pacific employees went to check on the equipment operator and found the RMM stopped on the tracks.
The steel grating panels had fallen from the clamping work head attachment. One panel was still partially gripped by the clamp, with one end of the panel stuck in the ground directly in front of the RMM and the other end extending through the broken front windshield of the machine.
The Union Pacific employees called 9-1-1. Emergency responders pronounced the equipment operator deceased on the scene of the incident. The cause of death was recorded as hemorrhagic shock. Post-accident toxicology tests found no drugs or alcohol.
Work wasn’t performed in accordance with specifications
NTSB investigators found that evidence and center-of-track impact markings at the scene of the incident were consistent with the equipment operator moving the RMM with the suspended load along the track. They confirmed that the steel grating panels came loose from the RMM work head attachment and a panel fell so that one end stuck in the ground and the other end was directly in the operator’s path of travel. As the RMM moved forward, the panel broke through the front windshield of the RMM and struck the equipment operator.
Investigators reviewed the equipment specifications for the clamping work head attachment and learned that this attachment was specifically designed for use with single crossties, not steel grating panels. By using the clamping work head to move steel grating panels, the operator wasn’t performing the work in accordance with equipment specifications.
The NTSB determined that the probable cause of the incident was the use of the RMM “to move a load of steel grating panels suspended in front of the machine with a clamping work head attachment that was not designed for use with such a load.”
Company now has rules governing proper use of equipment
At the time of the incident, W.T. Byler had a safety training and inspection program, but RMM operator training was conducted by the equipment vendor, Ballast Tools Equipment. W.T. Byler didn’t have rules related to transporting suspended loads with RMMs.
The company now has rules requiring that RMM operators position suspended loads over the field side of the track during transport and use tag lines to stabilize them or, if this is impossible, use rail carts to
transport loads along tracks. The use of clamping work head attachments to move panels is now prohibited by the company.
Can this equipment do the job safely? Best answered with a JSA
Some jobs require workers to adapt to changing conditions. A plan may initially call for a certain type of tool, but when the workers start the job in the field they may find the situation has changed and a different tool may be a better a choice. This happens in a lot of different industries.
This can become a big problem if safety isn’t taken into consideration. If a worker thinks only about getting the job done, like the equipment operator in the NTSB investigation did, then there could be deadly consequences.
The question isn’t, “Can this equipment do the job?” Rather, it’s, “Can this equipment do the job safely?” This question is often answered best with a job safety analysis, which was likely used to initially choose the best equipment for the job.
