Document 91eVKNKeeB8GEJJmp6jB5Eqk3

e-- ABD00313511 To: R. W. Seymour Interoffice Communication From: Dote: Subject: D. C. Skokna April 17, 1989 ACCIDENT INVESTIGATION - DOUG SPANN INJURY VISTA Summary At approximately 10:00 PM on Wednesday, April 5, 1989, Doug Spann (Yard "A" Operator) fell while descending a ladder on hopper car GACX73381. The fall caused a dislocated left thumb, multiple fractures to his left fibula, and torn ligaments in Doug's left leg. First aid response by Roy Ray, Daniel Loftin, and Red Jones was well done. Doug received treatment at AMCH and GTR hospital. The cause of the injury was the inferior design of railcar ladders combined with a high frequency of using these ladders. Recommendations are to construct permanent platforms to access the tops of railcars for routine loading. Injured Employee - Doug Spann Job Classification - Yard "A" Operator Job Experience - 2 1/2 years Plant Experience - 20 years Description of Iniurv Dislocated left thumb, multiple (3) fractures of the left fibula, and ligament damage related to the fracture. Treatment First aid provided by Roy Ray, Daniel Loftin, and Red Jones. Doug was transported to AMCH by ambulance where he was examined and kept overnight for observation. On April 6, 1989, he was taken to see Dr. Rhea in Columbus. Dr. Rhea put Doug's thumb in a cast to immobilize it and recommended surgery to repair ligament damage in his left leg. The surgery was performed at GTR hospital the afternoon of April 6. Also, Doug's left leg was put into a cast. He was released to go home on Friday, April 7. ABD00313512 Accident Investigation - Doug Spann 04/17/89 Page 2 Events Leading to the Injury 1. Doug loaded hopper car GACX-73381 with resin. 2. After sealing the car, Doug descended the railcar ladder ("A" end). See Attached Photo. 3. While coming down the ladder, he released his right hand to move to the next rung (at this point his left hand was on the #1 or #2 rung). 4. Next', his foot slipped, and he fell. Doug was not able to stop the fall with his left hand. 5. During the fall, Doug's right shin was bruised (indicating a vertical fall). On the way down, his right leg struck something (probably the coupler handle) that caused him to twist away from the car (twisted to the left). 6. He landed on the concrete paving west of the car, probably on his left leg and leftjhand. Cause of the Iniurv Climbing railcar ladders is a routine job done many times every day. Railcar ladders are inferior to the ladders used on process equipment. This particular ladder had these deficiencies: 1. Spacing between rungs was 18" vs. the normal 12". 2. The rungs were smooth. 3. There is only a 2" clearance between the rung and the railcar shell on rungs #1 and #2. The team believes that Doug was doing a routine job on a ladder that is not well designed. Experience indicates that slips on railcar ladders are not an unusual event. When Doug slipped, he was not able to prevent his falling and the subsequent injuries. There were no unusual weather or lighting factors. Examination of his shoes showed they were in good condition with a small amount of mud on them. The team did not consider this as a contributor to the accident. ABD00313513 Accident Investigation - Doug Spann 04/17/89 Page 3 Recommendations 1. Install permanent platforms to access the tops of hopper cars in the vinyl and compound departments. 2. All departments should review this injury during April to emphasize safe ladder practices. 3. Contact the Safety Directors of the other Vista plants to see if there are similar situations and how they are done (Example: how does OKC access and load hopper cars). 4. Send Compound Department hopper car inspection reports to the Yard crew prior to loading compound cars (While not directly related to this injury, this is a good recommendation.). ABD00313514 / // n - s Chairman - D. C. Skokna l/s*-- B. L. Trego - Safety J R. Gates o-1 ,---- --L - .. / Yard , ijt, f 0~ctl L. D. HoneycuttI - Yard // V; L */ T. L. Noland - Compound D. Spann7- Yard r P. J. Kober - Vinyl/Yard 83