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ReviewoftheFatalAccidentinaManureSiloinMakkinga

AbouttheAccident:

TheaccidentoccurredatadairyfarminMakkingaon19June2013.Oneemployeefromaspecialisedcontractor
becameunwellwhilecleaningthesilo.Inthesubsequentrescueattemptofthreeothermenbyenteringthesilo
leftallfouroftheminsemiconsciousstateduetoinhalationofthemanuregases.Later,threeofthemendied
andthefourthmanwasadmittedtohospitalwithseriousinjuries.

Theaccidentisnotoneofitskindasinrecentyears,anaverageofatleastthreeseriousmanureaccidentshave
occurredeachyear.Apparently,thereareseveralmanurehandlingaccidentswithlessseriousconsequencesthat
arenotpart ofthestatistics.Suchaccidents,evenafteragriculturalsectorsawarenessofmanuregas hazards,
mustinitiaterelevantactiontoavoidsimilarfutureoccurrences.

AssessmentofCausalFactors:

Themanuregasaccidentscanbediscretisedasaccidentsthatoccurredwhile:
1. mixingmanureslurryinaconfinedspace,and
2. enteringconfinedspacesthatcontainedorhadcontainedmanureslurry.
Bothofthesetypescanbeattributedtotechnicalfactors,humanfactorsandorganisationalfactors.

TechnicalFactors
1. Needtoentercellartorectifyamalfunction
Thedesignofsilosissuchthatmixingofmanureunderashedisperformedunderinadequateventilationand
nobarriertopreventpersonsoranimalsfromenteringpotentiallyhazardouszones.
2. Nonexistentordefunctsafetyequipment
Themultigasdetectordidntensurethattheemployeesleavesilointime.Also,therespiratoryprotection
didnt prevent the employees inhalation of hazardous concentrations of manure gases. Moreover, no
equipmentwasavailabletoenablerescuerstogetthevictimoutofthesilosafely.
3. Developmentofmanurepolicyanddesignofmanurestoragereservoirs
Theriskofbeingexposedtohazardousconcentrationsofmanuregasesisenhancedbytwodevelopments.
Firstly, due to substantial increase in cattle and pig farming, larger sheds to accommodate more manure
increase manure gas risks. Finally, governments introduction of more stringent manure policy to cover
manurestorageroofsandlowemissionslattedfloorhaveintroducedoccupationalsafetyrisks.
4. Activitiesforbusinesseconomicreasons
Additionofflushingwaterfromairscrubberstomanureslurryforeconomicbenefitspromotesformationof
hazardousmanuregases.

HumanFactors
1. Failuretotakesufficientaccountofmanuregashazards
Themembersoftheprofessionalgroupsinvolvedareawareofthefactthatinhalationofmanuregasescan
behazardous.Eventhen,theyregularlybecomeoverwhelmedbythegasandresultsinanaccident.
2. Naturaltendencytorescueinanemergency
The need to rescue is enhanced in such situation of acute emergency. Due to lack or absence of potential
rescuersintheareaandthevictimoftenbeingamemberofthefamilyoracolleague,bystandersinstinctively
rushtohelpthevictim.Thereisarealhazardthattheywillsuffersevereinjuryordeath.

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3. Tendencytohidemanureaccidents
Learning of safety lessons from accidents and dissemination of knowledge is limited due to tendency of
involvedauthoritiestohushupmanureaccidents.

OrganisationalFactors
1. Lackofsafetyprecautionscommensuratewithnatureandextentofrisk
Involvedauthoritiesdonotreviewrisksinvolvedinmanurehandlingtodetermineadequateprotectionand
procedurefororganisingthework.Therespiratoryprotectionequipmentarenotcompatiblewiththelevel
ofriskinthemanuresiloandnoequipmentisavailabletoperformrescueoperation.
2. Absenceofspecificworkinstructions
Theoccupationalsafetyinstructionslistedinworkingconditionscataloguesdonotlaydownspecificsafety
measures for working in confined spaces that may contain manure gases. In absence of such instructions,
companiesdontadoptaconsciousapproachtomanuregasrisks
3. Limitedsupervisionofoccupationalsafety
Largenumberofthoseinvolveddonotrealisethatathighconcentrationsofmanuregasesasinglebreathis
enough to cause loss of consciousness. In such scenario, role of Labour Inspector to ensure adoption of
instructionsmentionedinworkcatalogueiscrucial.Butoftenitsactivitiesarelimitedtoresponsestoserious
accidentsandtheinspectorsinvestigationofaccidentsdoesnotextendwhereonlyselfemployedpersons
areinvolved.

Precautions:
1. More awareness of the risks will promote adoption of safer working method and reduce tendency of
bystandersrushingtorescuesomeonewithoutensuringpersonalsafety.
2. Ensure active learning of the persons involved in manure handling through a platform for collection of
knowledgeaboutmanuregashazardsandsafetylessonslearntfrommanuregasaccidents.Also,ensure
workingsafelywithmanureasstructuralelementoftrainingatagriculturaltrainingcentres.
3. A working conditions catalogue must supplement with specific instructions in safety measures to be
implementedwhileworkingwithmanureinconfinedspaces.
4. The government authorities must devote sufficient attention to the control of risks associated with
manuregaseswhileincreasingstringencyofenvironmentalregulations.

Inaddition
Inmypointofview,apartfromtheprecautionssuggestedinthereport,theformulationofaGuidelineforsafe
workinmanurestoragereservoirwiththeinvolvementofanauditingauthoritytocheckimplementationofthe
guidelinesandsafetyequipmentwillreduceandsubsequentlyavoidoccurrenceofaccidentsasseenatMakkinga.
TheDutchSafetyBoardmustmakesubstantiveassessmentoftheguidelinesuntiltheoccurrenceofaccidentsis
completelyeliminated.

Source:
DutchSafetyBoard(http://www.onderzoeksraad.nl/en/)