Report lays out 2016 Anniston Army Depot workplace death
By ZACH TYLER | The Anniston Star (Tribune News Service) | Published: March 1, 2017
It was a Tuesday afternoon in September, and Willie Moon wasn’t answering his radio.
Earlier that morning, the 64-year-old machinery mechanic at Anniston Army Depot had received a call: The third crane in a mostly automated storage warehouse on the installation needed service.
He’d set to work shortly afterward, witnesses would later tell Army investigators, lying down alone in front of one of the hydraulic scissor lift systems serving the warehouse crane.
Around 11:30 a.m., Moon used his radio to say he’d taken the crane offline for maintenance. When depot employees tried twice to contact him just after 1 p.m, Moon didn’t answer.
Almost two hours later, an assistant coroner pronounced the mechanic dead.
According to a U.S. Army Criminal Investigation Command report, the investigation begun that Tuesday would show Moon died as he worked — alone, pinned beneath a lift he had taken no precautions to secure. The report was obtained recently by The Star through a Freedom of Information Act request.
The depot’s safety chief said Moon had been trained repeatedly on facility safety procedures, drafted on federal regulations, for repair of such equipment — though the installation was cited recently by the Occupational Safety and Health Administration for those procedures. When followed to the letter, experts said, the federal regulations on which the depot’s procedures are based do much to safeguard the lives of workers in hazardous industrial settings.
No one saw
The Army report compiles photographs and witness statements collected by investigators in the weeks after Moon’s death. While the identities of investigators and witnesses are redacted, the document sketches a picture of how Moon was killed — though no one saw the accident that caused his death.
The retired Army sergeant had worked 13 years at the depot, and was eyeing retirement again. On Sept. 6, based on witness statements in the report, he spent a large part of the morning working alone on the troubled crane and lift system.
A depot worker last saw Moon alive near a break room around 12:40 p.m. Photos in the report show he left a lunch of two sandwiches and a box of Cracker Jacks uneaten in his office.
In an email, the depot’s safety officer said supervisors bear direct responsibility for safety of their employees. They’re trained to assess the risk of jobs needed done, and seek ways to minimize those risks, the officer said.
“Mr. Moon’s supervisors determined that the day-to-day tasks assigned to Mr. Moon could be safely accomplished without the assistance or oversight of additional employees,” wrote Andrew Ramsey — a decision based on Moon’s “training, experience, and expertise.”
Sometime after 12:40 p.m., Moon crawled underneath the lift system, wrench in hand, perhaps to fix an oil leak. He was on his right side, left arm extended into the hydraulic mechanism that powered the lift.
At the time, the lift was raised, likely enough for Moon to adjust a hose that fed and drained oil from a reservoir to raise and lower the platform. While he worked, the hose snapped off of the reservoir. The hydraulic oil that’d kept the lift overhead drained quickly. The lift came down.
‘It was no use’
Depot workers wouldn’t find Moon trapped until about 1:45 p.m.
“He wasn’t moving nor talking,” one told investigators. Before the depot’s fire and rescue personnel got to the building, one of the workers tried to use a forklift to rip the machinery on top of Moon out of the concrete.
“It was no use, because the way he was lodged in, would have tore his head off,” another witness said.
Several witnesses said they’d seen no evidence Moon had tried to secure the lift by chaining it up and physically block its descent with blocks of wood.
Maintenance employees receive regular training on the depot’s “lockout/tagout program,” according to Ramsey, an eight-step checklist based on regulations enforced by the Occupational Safety and Health Administration, or OSHA.
Those federal regulations mandate employers protect employees who operate or service potentially dangerous machinery, specifically by developing a program to ensure the machines are motionless during maintenance.
Depot records show Moon received that training “on multiple occasions,” Ramsey said.
Another witness — an electrician in Building 513, where Moon was killed — told investigators he wouldn’t work underneath one of the lifts without blocking it off in three different ways.
“To my knowledge there is no written statement telling anyone what you are to do,” the electrician said. “Keep in mind that we don’t work on these table/hydraulic lifts often.”
OSHA was involved in the multi-agency inquiry that started after Moon’s death. A spokeswoman said the depot is currently appealing a notice of violation from the safety agency regarding the installation’s lockout/tagout program.
Clester Burdell, the spokeswoman, declined to release the notice, saying that the Army considers it preliminary pending the conclusion of its appeal, so it is unclear what issue the agency found with the depot’s program. A request to OSHA for the document was unfulfilled as of press time Tuesday.
The depot’s workers — who refurbish the Army’s tanks and other armored vehicles, as well as small arms — are unionized, members of the American Federation of Government Employees Local 1945.
The local’s president this week praised the safety-focused culture he sees cultivated by the depot’s commanders and supervisors.
Each morning across the depot, Charles Barclay said, employees with tasks “from housekeeping to working with machinery” have a safety meeting, with lockout/tagout discussed each time.
“We talk about those issues every day, and try to prevent any other type of event like that, at that level,” Barclay said, referring to Moon’s death.
Barclay said the union engages in continuous negotiations with the depot’s leadership on job hazards and worker safety. Some of those negotiations deal with the type of work Moon did, but Barclay declined to discuss them, citing the depot’s appeal to OSHA.
Culture of safety
Even in hazardous work environments, surrounded by heavy machinery that can crush and maim, industrial safety experts said, employees who follow a clearly communicated policy for stopping those machines based on OSHA’s regulations are often protected from accidents.
“If it’s done properly, people that are covered ... should be safe,” said Jack Green.
Now a forensic investigator at the firm Robson Forensic, Green spent nearly three decades working at a power plant where federal regulations informed safety policies.
“We never lost a man,” he said.
Accidents tend to happen when employers don’t do a good job communicating the correct procedure, or when employees feel pressured to skip steps to save five minutes off production, according to National Security Council expert Wes Scott.
“The maturity of the safety culture in the organization determines whether that’s five minutes well spent or not,” said Scott, the council’s director of workplace consulting and training.
“Those companies don’t mind an extra five minutes if their employees go home safe,” he said.
A strong safety culture often goes back to the level of risk employees face while working, Scott said. The most dangerous jobs often carry tough discipline for employees who shirk safety policies, he said.
Ramsey, the depot safety chief, said that employees would face consequences for violating training guidance, but did not specify what those consequences could be.
Recommendations from the investigation into Moon’s death have been “managed to completion,” he wrote, and included talking with staff about what happened that day, reviewing hazard analyses for depot jobs, and “verifying that managers and supervisors were trained in deliberate risk management.”
In an October 2016 email referenced in the Army investigation report, the general directing the U.S. Army Tank Armament Command noted Moon’s death was a preventable tragedy.
The major general, his name redacted, offered “condolences to all those affected by the tragic workplace accident,” according to the report.
He mentioned “key areas he wanted revisited across the facilities under his command,” the report said, including a review of job hazards analyses “and the implementation of the ‘buddy rule’ when maintaining industrial equipment.”
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