MacDill Air Force Base changed some of its rules for handling cargo in the wake of the death in January of a staff sergeant who was crushed by a KC-135 refueling boom in a warehouse.
Air Force Staff Sgt. Emily Elizabeth Clayburn, 29, was killed instantly shortly before 3 p.m. Jan. 14 when a crated refueling boom supported by two warehouse dollies rolled off a loading dock and landed on her, according to a 518-page Air Force report.
The incident took place at the 6th Logistics Readiness Squadron warehouse. The boom was being shipped out because it wasn’t serviceable at MacDill. The report outlines what investigators found happened next.
At about 2 p.m., a commercial semi-trailer arrived at the warehouse to pick up two pallets of cargo. There were two booms on each of the loading docks and one of the booms needed to be moved so that the pallets could be loaded onto the truck.
Clayburn and another airman began to move the boom on Dock 2, using two four-wheeled dollies “as members of the unit had done on previous occasions to allow access to the truck.”
As Clayburn brought the dollies on the dock, the other airman, who is not named in the report, drove a forklift in front of the dock to lift the crated boom, so that the dollies could be moved underneath. After moving both dollies into place, Clayburn set the wheel brakes on the dollies wheel closest to the building side of the dock. The other airman, meanwhile, climbed off the forklift and set the brakes on the dolly wheels closest to the street side.
The second airman lowered the boom onto the dollies and began to drive the forklift back into the warehouse. Clayburn then walked down the stairs next to the loading dock and released the brake levers on the dolly on the left side of the boom. She then walked to the right end of the boom to release the levers on that dolly.
That’s when the left end of the boom began to roll off the dock.
The truck driver, who was about 30 feet away at the back of his truck, saw what was happening and yelled to Clayburn that the left end of the boom was moving.
Clayburn was unable to get out of the way and the boom landed on her, killing her instantly.
Investigators learned that on the day of the accident the warehouse was handling about 80 pieces of cargo, which was about twice as much as a “typical day,” with fewer personnel available, according to the report.
The cargo included three refueling booms, which weigh more than a ton a piece.
“Only two outbound cargo personnel were present” at the warehouse “and available for outbound cargo duties at the time of the incident,” according to the report. Investigators’ “demonstrations and observations suggest at least three people are needed when using the dollies for moving large items.”
The report found that “supervision did not recognize the inherent hazards associated with materials placed on wheeled platforms at the edge of a loading dock and did not develop or implement local guidance for handling large/heavy cargo or perform a [Job Safety Analysis] to mitigate risk as demonstrated by the fact that no [Job Safety Analysis] had been documented nor large cargo, warehouse special handling procedures implemented.”
The problems were exacerbated by the assumption that equipment like warehouse dollies “were simple to use,” according to the report.
After the accident, MacDill “developed and implemented a checklist that all employees are required to follow, increased the number of employees to perform certain tasks and requested additional funding to physically change some work areas,” Terry Montrose, a spokesman for the 6th Air Mobility Wing, said in a statement to The Tribune. “Serving our nation in the military is a dangerous job, but MacDill places job safety as our top priority, and will continue to look for ways to keep our Airmen safe.”
Clayburn’s mother, Michelle Clayburn, said she is satisfied with the results of the Air Force investigation.
“Everything was done in a timely manner with respect for the family,” she said.