706 Conducting a Job Hazard Analysis

In June 2020, a serious incident occurred at a manufacturing facility in Ohio involving a batch operator working with a concrete mixer. The mixer discharged concrete through a pneumatic door designed to remain open when its pneumatic energy was released via an exhaust valve. However, the handle of that valve had broken off and had not been repaired or replaced.

Because the pneumatic shut-off function was compromised, the batch operator attempted to close the discharge door manually. During this process, the door closed unexpectedly, causing a severe head injury. The operator was transported to the hospital and died five days later.

A federal investigation led to a workplace safety citation, a $500,000 fine—the maximum allowed—and a court-ordered Safety Compliance Plan.

This incident highlights the importance of identifying both hazardous conditions and unsafe behaviors during job development and ongoing job hazard analysis:

• The broken valve represents a hazardous condition that should have been flagged through routine equipment checks or maintenance records.
• Resources like safety inspection reports, maintenance logs, and incident histories are essential for spotting recurring hazards.
• Employees familiar with the task can offer insights into real-world behaviors and equipment conditions that may not appear in the procedure manual.
• Manually operating a powered door in the absence of a functioning control was likely viewed as a necessary workaround—but it introduced unintended exposure to risk.
• Job Hazard Analyses (JHAs) should consider how tasks are carried out when controls are missing or not functioning—not just how they’re designed to be performed.