OSEA Safety Blog

Cascading Events to Tragedy

Monday, October 22, 2018 John Coniglio

Oil/Gas Pump Jacks;

You have seen them in the country side, mountain areas and the plains. They are mechanical devices that look like large ‘teeter totters’, used to pump up oil & gas. They are usually located away from areas frequented by individuals; well they used to be!

As housing expands and areas where energy reserves are located they are now seen in neighborhoods and farm fields with nearby housing and, yes, children. This is where the problems begin. How do we protect them from entry, one truly considered an attractive nuisance that invites exploration, especially by children.

In one such case 12 and 16-year-old sisters were walking with their parents across a farm field, just out for an evening walk. The children, obviously full of energy, went ahead of their parents with the admonition to stay away from the pump jack equipment up ahead. The sisters got to the pump jack well ahead of the parents and entered the operating area. This is because the only protection that was provided was by animal or cow fences with large openings easily entered and worse, the gate was open. At some point the older sister encouraged the younger girl to get on the unit, remember it looks like a ‘teeter totter’. By the crank and gear box her leg was caught suffering a serious leg injury. On the day of trial, parties settled avoiding a final decision as to the appropriateness of the protection provided.

The industry feels that the current methods are adequate and private property incursion was the cause. The fencing was adequate, and they trespassed leading to the accident. The property was not marked, “No Trespassing” and was frequently entered by individuals just walking or heading toward a local fishing pond. Regulations were in fact sparse as it relates to fencing and the void of direct requirements complicated the issue of liability. Is there an obligation to fully fence (chain link) the area? With homes now built in many areas where this equipment is present now require a re-thinking of specific requirements to fully protect? In many areas this equipment has fencing now with all equipment including 480-volt power supplies for motors open for entry.

This accident shows that equipment even when located in remote, thought to be uninhabited needs the same protection equipment receives in the workplace. We would never allow a moving piece of equipment like a pump jack to sit on a plant floor without full protectives placed and a requirement to de-energize when entering the space. Yet we have not, even though consensus standards put forth such a requirement. It’s now time!

Another concern relates to the power supply. Depending on the energy source being tapped, levels of natural gas/methane can be found around the equipment. The areas are wide open, and it does dissipate quickly, most of the time. Yet wiring used does not in most cases meet the requirements of the National Electric code for Hazardous Locations. This is a complex area requiring risk assessment to consider the exposure to prevent an accident. Wiring needs to be enclosed, explosion proof for category of hazard and set procedures set for open flame work.

It is time to review these areas and initiate safeguards and specific regulations before more individuals are injured.


How many times have you walked by something and thought why is it there like that while no one is using it? In this instance a 36’ fiberglass extension ladder had been placed on a large concrete pedestal. It was a twin of a similar pedestal being erected to accommodate a motor on one and a large shear on the other connected by a drive transmission. The placement of the equipment needed to be exact to allow proper connection and operation. The ladder was placed by a surveyor who went on top to check the lug placement for the base of the motor. He became frustrated when he found it out of place and just left, leaving the ladder, not tied off nor secured. We found this out through his testimony because something tragic was to occur.

It was established that the ladder remained in place for three days. Numerous people used it and many more walked by it, maybe wondering why it was there perhaps, unsecured, unused…just there! Nearby, a construction laborer was working on footers for a concrete pour. While not directly in the area but well within the ladders reach at some point, either the wind gusting off the ocean nearby or a crane swinging by with a wire rope sling working on the other pedestal caused the ladder to fall. The ladder came down sideways and struck the laborer, a 36-year-old individual, on the head breaking his neck. Hard hats are not enough protection in this case. Eight days later he died from his injuries.

What cascading events led to or caused this tragedy? Was it the original setting of the ladder- root cause? Was it the 3 days of inattention by numerous individuals who took no action seeing it sitting there unsecured and essentially unused. How many times do we walk by these type situations without questioning why? Situational awareness is important, question things when they don’t seem right. It could save someone’s life.

Following the rules, well almost;

Iron workers were finishing up the decking on a 2-story building. It was Friday and they had just completed their work with one of the workers noting that they needed to cover the openings left for roof access. Having recently completed his OSHA 10-hour outreach training he told the crew members they needed to cover the openings with plywood.

Working nearby was the roofing crew who were staging their equipment and supplies. They had placed several sheets of plywood on the deck, so they could later hoist up and place their equipment and supplies. At the end of the day they left and the Ironworkers noting the need to cover the holes and used several of these sheets to do so. The problem was while they remembered to cover the holes they forgot the rest of the requirement. Mark the covers as “HOLE” and mechanically secure them from movement.

Saturday morning the roofers came to work. They hoisted up materials and seeing their plywood sheets went to retrieve them, so they could place their materials on them to protect the deck. Well at one such large opening two of the workers went to retrieve a sheet each picking up an end and walking forward. The unlucky individual walking forward to the rear walked right into the opening unseen by the 4x8’ sheet of plywood he was carrying. And yes, he walked right into and through the opening falling to the next level. You’re on a roof and openings should be expected. You cover a hole but don’t secure it and mark it. You receive training but don’t put it all to use. Cascading events to tragedy!

These are not internet posted pictures of sad representations of unsafe acts. These are real cases of incidents that led to tragic result that we need to think about as we go about our work.

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