Marine crushed by slow-moving steel door

Marine crushed by slow-moving steel door

Hindsight after a terrible mishap is always 20:20, but sometimes you look at a mishap scene and just shake your head because it looks like it was always a mishap waiting to happen. All the elements were there, and it seems surprising that it hadn’t happened before.

In this case, a PFC at an ammunition supply point (ASP) was crushed by an 8-foot-by-10-foot, electric door on an ammunition magazine while trying to arm the facility’s security apparatus. His heart was stopped long enough to leave him brain dead.

Here’s how it happened. The PFC had been a basic ammunition technician for two and a half months. He and three other Marines are in the ASP compound when the team leader says it’s time to break for lunch. The PFC is handed the magazine keys and told to begin closing the open magazines.

The magazines have an intrusion detection system (IDS). Once the system was armed, an alarm went off if the door didn’t close in a certain amount of time. In order to avoid setting off the alarm, the Marines had developed a procedure. From inside the magazine, they’d start the door moving, watch as the door slowly closed then hit the alarm arming switch, and scoot outside between the moving door and the door frame. Once outside, watch the door slam shut, then they would finish locking the door and securing the door-lock cover.

They thought they had 30 seconds from the time the system was armed until the alarm went off, so they had to gauge when to punch the arm switch to allow just enough time to exit.

Seems dangerous, since the huge door can squash you? Indiana Jones made it and so did these Marines until this day. When you do something enough, it starts seeming routine. This time, the PFC misjudged the distance or got distracted. As he sidestepped from left to right between the door and frame, a steel projection snagged his blouse, either the PFC couldn’t rip loose or momentarily paused to unhook his clothing–we’ll never know.

A few moments went by. The electric motor strained to close the door but the PFCs chest ground the motor to a halt, which caused it to overheat and trip a circuit breaker. At about the same time the IDS system went off. Marines from the compound run by the magazines to investigate and PMO phones to see if there is a problem. The ASP Marines found the PFC pinned between the door and the frame. The three other Marines realized that the PFC Marine was caught in the door. They hurriedly tried pushing the open button, switching the door from electrical to manual, and then set out to push the door open. None of these frantic actions did anything.

One Marine ran to the guard shack, where he dialed the emergency number and then called the SNCOIC. The emergency call brought vehicles from the PMO, the fire station and the base dispensary. Meanwhile, another one of the Marines got a forklift and positioned it with one fork between the pinned Marines legs against the door of the magazine.

The SNCOIC arrived and also tried pushing the control buttons, switching the door from electrical to manual control. He also tried to push the door open. Once again these efforts were fruitless, he returned to the manual arming lever and pushed and pulled so hard that the steel handle eventually snapped.

The forklift driver tried to push open the door, squealing and eventually shredding them. It didn’t work. When PMO arrived, they pulled their 1/2 ton truck behind the forklift. They slowly accelerated to lean against the forklift. Even pushing at the same time, the track and forklift couldn’t budge the door. PMO then tried to wedge the door apart with a car jack. That didn’t work, either. By now, the fire truck and ambulance are at the scene.

Desperate, PMO got back in their truck, backed up and squared off with the forklift. Using their truck as a hammer they rammed the back of the forklift. This act succeeded, broke the door drive chain, and knocked the door open about five feet. The freed PFC fell to the ground. EMS personnel put him on a stretcher and put him into the ambulance, which speeds him to a local hospital. The medics did CPR along the way. At the hospital, a trauma team put in a breathing tube and restarted his heart. Seriously injured, he ended up in intensive care on a ventilator.

Tests on the magazine door showed that both the electrical system and the manual system on the door were working. They also revealed that the IDS system alarm goes off after 60 seconds, not 30 seconds, so the Marines had twice as long as they thought and could have exited the magazine when the door was farther open.

So one problem immediately came to light. The PFC and all the Marines working in the ASP hadn’t had enough training on how to operate the doors. All training was OJT, which is fine as long as it is correct, but in this case it wasn’t. The best training includes theory, practical application, and tests to make sure that the people in the class know enough before they’re allowed to do anything without supervision.

In this case, the Marines who were training others how to operate the doors had no written guides to assist them. They didn’t fully understand the intrusion-detection system, or all of the aspects of operating the doors manually and electrically. They had heard verbal explanations of how to use the manual system to open and close the doors, but hadn’t practiced it. They didn’t know what to do when the system lost electrical power. As a result, no one knew what immediate actions to take during an emergency. They also didn’t know how to put the magazine door into manual operation, nor did they know how to check the circuit breaker (which had tripped off early in this tragedy) when the door was operating electrically. The electric motor driving the door had overheated, tripping the circuit breaker, but the electric motor, circuit breaker, manual controls, and all gearing was working normally. If someone knew to switch the circuit breaker to off then on, power would have been restored and the open and close button would’ve worked.

The manual control also worked. This system had a select lever that disengaged the gears from the electric motor over to a gear spun by hand using a chain driven mechanism commonly seen on industrial garage doors. To switch from electric to manual, the chain drive must be slowly rotated while the lever is moved from electric to manual. This allows the gear teeth to line up and mesh. This system worked properly, no one new to slowly rotate the chain while moving the lever to manual. If you think of a car, these Marines were essentially jerking on the gear-shift then pushing on the clutch. They repeatedly tried until the handle snapped and they sought other methods.

The SOP used at this ammunition supply point was inadequate. They weren’t using a signed SOP, but were instead using an unsigned and undated one. This appeared to be a later version, but it didn’t matter anyway because both SOPs lacked details about how to operate the doors. The lesson here is to make sure that your SOPs are correct and that they have enough detail to cover contingencies and problems. Make sure everyone uses the SOP, and when a new one comes out, hold training to discuss the changes.

The “S” part of SOP should ensure that everyone does a job the same way. In this case, each ASP Marine had a different estimate of where the closing door had to be before they stepped out of the magazine and completed the procedures.

In terms of Operational Risk Management, no one had realistically identified the hazard of stepping in front of a huge, moving, steel door, and as a result, no controls were in place that would have prevented this mishap. As it turned out, no one had to walk in front of a moving door at all; the system allowed for the door to be stopped while the IDS was armed, and the alarm delay was long enough Marines could exit the magazine and restart the door from outside without ever walking in front of it while it was moving.

Several recommendations came out of this completely preventable mishap:

* Place a warning on the magazine doors in large letters: “Do not walk in front of moving door.”

* Paint a line on the deck to show exactly where to stop the magazine door while arming the IDS system.

* Standardize procedures.

* Conduct quarterly training with ASP Marines on immediate action steps, including how to operate the doors manually and how to reset the circuit breaker.

* Formalize the indoctrination on operating the magazine doors and include it in training jackets. Make an entry when a Marine can open and close the magazine doors without supervision.

Don’t get used to things that are needlessly dangerous. There are plenty of real, unavoidable hazards involved in combat; we don’t need to create others because of a lack of knowledge.

Keep asking questions: Is this the best way and the only way? The answers might keep one of your fellow Marines out of a wheelchair

COPYRIGHT 2002 U.S. Navy Safety Center

COPYRIGHT 2003 Gale Group