Lesson Learned - Employee's Toes Crushed by Falling Compressed Gas Cylinder

What happened?
In February 2007, a University of California, Berkeley (UC Berkeley) researcher was loading a gas cylinder on a two-cylinder cart when the previously loaded cylinder fell and crushed his toes.

What was the cause of the accident? What were the contributing factors?
The most likely cause of this accident is the fact that this two-cylinder cart had no means to secure both cylinders independently. Therefore, when positioning the second cylinder on the cart, there was no way to secure the first cylinder. Loading the second cylinder puts the first cylinder at-risk for falling. Cal/OSHA, and good safety practices, require that compressed gas cylinders be transported in a manner to prevent them from tipping, falling or rolling.

General Industry Safety Orders §4650. Storage, Handling, and Use of Cylinders.
(e) Compressed gas cylinders shall be stored or transported in a manner to prevent them from creating a hazard by tipping, falling or rolling.

Cylinders are transportable, but potentially dangerous if not handled properly. They are at significant risk of falling when left unrestrained.

A secondary cause of the accident was that the victim did not recognize the potential for this accident. In the course of the investigation, the victim reported a history of several near misses specific to almost dropping the second cylinder during transfers.Had the near miss potential been analyzed, this accident might have been prevented.

What corrective action has been taken?
This particular cart, and others like it, have been taken out of service and will be replaced with compliant carts.

Lessons Learned

How can incidents like this be prevented?

  1. Survey two-cylinder transfer carts that are currently in service and check to see that all two-cylinder transfer carts are equipped with the capacity to secure each cylinder independently.
  2. Remove or repair carts that do not have independent restraining chains.
  3. In the interim, using the two-cart device must be considered to be a two-person job, especially during the cylinder transfer portion of the job.
  4. In lieu of numbers 1 and 2 above, replace the carts with single cylinder carts.
  5. Be mindful of near miss events. A near miss is a potentially serious accident that did not happen. Learning about potential dangers involved in the work related activities can help to avoid a reoccurence of common accidents in the future.

Look for these features on carts that are designed to transport two or more cylinders.

cyclinder cart  Note: When transporting cylinders, one chain is sufficient to secure the cylinder(s).