Crestview Grain Corporation (CGC) m

Crestview Grain Corporation (CGC) maintains ten large silos for storing corn, rice, wheat, barley, and various other grains. Since stored grain generates fine dust and gases, ventilation of the silos is important. Consequently, all of CGC’s silos have several large vents. Each of these vents uses a filter similar to the type used in home air conditioners that must be changed periodically.

There is an element of risk involved in changing the vent filters because of two potential hazards. The first hazard comes from unvented dust and gases that can make breathing difficult, or even dangerous. The second hazard is the grain itself. Each silo has a catwalk that runs around its inside circumference near the top. These catwalks give employees access to the vents that are also near the top of each silo. The catwalks are almost 100 feet above ground level, they are narrow, and the guardrails on them are only knee high. A fall from a catwalk into the grain below would probably be fatal.

Consequently, CGC has well-defined rules that employees are to follow when changing filters. Because these rules are strictly enforced, there had never been an accident in one of CGC’s silos; not, that is, until the Juan Perez tragedy occurred. Perez was not new to the company. At the time of his accident, he had worked at CGC for over five years. However, he was new to the job of silo maintenance. His inexperience, as it turned out, would prove fatal.

It was time to change the vent filters in silo number 4. Perez had never changed vent filters himself. He hadn’t been in the job long enough. However, he had served as the required “second man” when his supervisor, Bao Chu Lai, had changed the filters in silos 1, 2, and 3. Since Chu Lai was at home recuperating from heart surgery and would be out for another four weeks, Perez decided to change the filters himself. Changing the filters was a simple enough task, and Perez had always thought the “second man” concept was overdoing it a little. He believed in taking reasonable precautions as much as the next person, but in his opinion, CGC was paranoid about safety.

Perez collected his safety harness, respirator, and four new vent filters. Then he climbed the external ladder to the entrance/exit platform near the top of silo number 4. Before going in, Perez donned his respirator and strapped on his safety harness. Opening the hatch cover, he stepped inside the silo onto the catwalk. Following procedure, Perez attached a lifeline to his safety harness, picked up the new vent filters, and headed for the first vent. He changed the first two filters without incident. It was while he was changing the third filter that tragedy struck.

The filter in the third vent was wedged in tightly. After several attempts to pull it out, Perez became frustrated and gave the filter a good jerk. When the filter suddenly broke loose, the momentum propelled him backwards and he toppled off the catwalk. At first it appeared that his lifeline would hold, but without a second person to pull him up or call for help, Perez was suspended by only the lifeline for over 20 minutes. He finally panicked, and in his struggle to pull himself up, knocked the buckle of his safety harness open. The buckle gave way, and he fell over 50 feet into the grain below. The impact knocked his respirator off, the grain quickly enveloped him, and he was asphyxiated.

The accident investigation that followed revealed that several factors combined to
cause the fatal accident—the combination theory. The most critical of these factors were
as follows:
• Absence of the supervisor
• Inexperience of Perez
• A conscious decision by Perez to disregard CGC’s safety procedures
• A faulty buckling mechanism on the safety harness
• An unsafe design (only a knee-high guardrail on the catwalk)

Hasil (Bahasa Indonesia) 2:

Crestview Grain Corporation (CGC) mempertahankan sepuluh silo besar untuk menyimpan jagung, beras, gandum, barley, dan berbagai biji-bijian lainnya. Sejak gabah disimpan menghasilkan debu halus dan gas, ventilasi silo penting. Akibatnya, semua silo CGC memiliki beberapa ventilasi besar. Setiap ventilasi ini menggunakan filter yang mirip dengan tipe yang digunakan dalam AC rumah yang harus diubah secara berkala. Ada unsur risiko yang terlibat dalam mengubah filter ventilasi karena dua potensi bahaya. Bahaya pertama berasal dari debu dan gas unvented yang dapat membuat sulit bernapas, atau bahkan berbahaya. Bahaya kedua adalah biji-bijian itu sendiri. Setiap silo memiliki catwalk yang berjalan di sekitar lingkar dalam yang dekat bagian atas. Catwalk ini memberikan karyawan akses ke ventilasi yang juga dekat bagian atas setiap silo. Catwalk hampir 100 kaki di atas permukaan tanah, mereka sempit, dan pagar pada mereka hanya setinggi lutut. Jatuh dari catwalk ke dalam biji-bijian di bawah ini mungkin akan berakibat fatal. Aturan Akibatnya, CGC telah didefinisikan dengan baik bahwa karyawan untuk mengikuti ketika mengubah filter. Karena aturan ini ketat, tidak pernah ada kecelakaan di salah satu silo CGC ini; tidak, yaitu, sampai tragedi Juan Perez terjadi. Perez tidak baru untuk perusahaan. Pada saat kecelakaan, ia pernah bekerja di CGC selama lebih dari lima tahun. Namun, ia baru untuk pekerjaan pemeliharaan silo. Pengalaman nya, ternyata, akan berakibat fatal. Sudah waktunya untuk mengubah filter ventilasi di silo nomor 4. Perez tidak pernah berubah melampiaskan filter sendiri. Dia tidak berada di pekerjaan cukup lama. Namun, ia pernah menjabat sebagai diperlukan "orang kedua" ketika atasannya, Bao Chu Lai, telah berubah filter di silo 1, 2, dan 3. Sejak Chu Lai berada di rumah memulihkan diri dari operasi jantung dan akan keluar selama empat lain minggu, Perez memutuskan untuk mengubah filter sendiri. Mengubah filter adalah tugas yang cukup sederhana, dan Perez selalu berpikir "orang kedua" Konsep itu berlebihan sedikit. Dia percaya dalam mengambil tindakan pencegahan sebanyak orang berikutnya, tetapi menurut pendapatnya, CGC adalah paranoid tentang keselamatan. Perez dikumpulkan harness nya keselamatan, respirator, dan empat filter ventilasi baru. Kemudian dia menaiki tangga eksternal untuk platform pintu masuk / keluar dekat bagian atas silo nomor 4. Sebelum masuk, Perez mengenakan respirator dan diikat di safety harness nya. Membuka tutup palka, ia melangkah masuk silo ke catwalk. Mengikuti prosedur, Perez melekat garis hidup untuk safety harness, mengambil filter ventilasi baru, dan menuju ventilasi pertama. Dia mengubah pertama dua filter tanpa insiden. Itu sementara ia mengubah filter ketiga yang tragedi terjadi. Filter dalam lubang ketiga terjepit di erat. Setelah beberapa upaya untuk menariknya keluar, Perez menjadi frustrasi dan memberi filter brengsek yang baik. Ketika filter tiba-tiba pecah, momentum mendorongnya mundur dan ia terjatuh dari catwalk. Pada awalnya tampak bahwa garis hidup nya akan terus, tapi tanpa orang kedua menariknya ke atas atau meminta bantuan, Perez diskors oleh hanya garis hidup selama lebih dari 20 menit. Dia akhirnya panik, dan dalam perjuangannya untuk menarik diri, mengetuk gesper nya terbuka safety harness. Gesper memberi jalan, dan ia jatuh lebih dari 50 kaki ke dalam butir di bawah ini. Dampaknya mengetuk respirator liburnya, gandum cepat menyelimutinya, dan dia sesak napas. Penyelidikan kecelakaan yang diikuti mengungkapkan bahwa beberapa faktor dikombinasikan untuk menyebabkan kecelakaan-teori kombinasi fatal. Yang paling penting dari faktor ini adalah sebagai berikut: • Tidak adanya pengawas • Kurangnya pengalaman dari Perez • Sebuah keputusan sadar oleh Perez mengabaikan prosedur keselamatan CGC ini • Mekanisme tekuk rusak di safety harness • Sebuah desain yang tidak aman (hanya pagar pembatas setinggi lutut di atas catwalk)