BRIEF DESCRIPTION OF INCIDENT

A temporary worker was fatally injured after falling through 

a sugar hopper and becoming engulfed by sugar. The fatality 

occurred in a marine cargo warehouse operation, where bulk 

granulated sugar from ships is transported to the warehouse for 

storage, bagging, and distribution. Sugar clumps often prevented 

the sugar from flowing freely through a hopper onto a conveyor 

belt during bagging. Two or three times per shift, workers would 

manually break up the clumps. This fatal incident occurred when 

the temporary worker was breaking up sugar clumps with a pole/

shovel while standing on a hardened sugar bridge at the top of the 

hopper (Figure 1). The sugar bridge collapsed. As the worker fell to 

the bottom of the hopper, his legs went through the chute where 

he was engulfed by sugar and suffocated.

Likely Causes of Incident

The host employer did not provide workers with a safe and healthful work environment: 

• There was a corporate safety program but it was not 

implemented at this work site.

• There were no site-specific safe work procedures for breaking 

up sugar clumps. 

• The hopper and chute openings were not guarded to protect 

workers from falling into the hopper and being engulfed by sugar. 

• There was no safe method or walkway to reach the top of 

the hopper and there was no safe work platform at the top. 

Workers had to reach a height of more than 13 feet to break up 

the sugar clumps.

• The workers (mostly temporary) did not receive appropriate 

safety and health training. 

• The supervisor, who was also a temporary worker, did not 

receive training in assessing potential workplace hazards and 

instructing other workers on how to avoid unsafe conditions.

INCIDENT SUMMARY

Incident type: ........Engulfment of a temporary worker in a sugar hopper

Weather conditions/Time of day: ...................... Indoors/approx. 1:30 p.m.

Type of operation: .......................Marine cargo warehousing and bagging

Size of work crew: ........................................................................................... 10 

Worksite inspection conducted: ................................................................Yes

Competent safety monitoring on site: .......................................................No

Safety and health program in effect: .........................................................No

Training and education for workers: ......................................................None

Occupation of deceased worker: ....................................................... Laborer

Age/Sex of deceased worker: .................................................................. 49/M

Time on job: .............................................................Approximately 9 months

Time at task: ...............................................................................2-3 times/shift

Employment classification (FT/PT/Temporary): .........................Temporary

Language spoken: ................................................................................Spanish

Union/Non-Union: .......................................................................... Non-Union

FATALFacts 10No. 10 – 2015

Engulfment in a Sugar Hopper

U.S. Department of Labor Occupational Safety and Health Administration www.osha.gov (800) 321-OSHA (6742)

Figure 1: Hopper-conveyor-bagger system

You Have a Voice in the Workplace

The Occupational Safety and Health 

Act of 1970 affords workers the right to 

a safe workplace (see OSHA’s Worker 

Rights page, www.osha.gov/workers). 

Workers also have the right to file a 

complaint with OSHA if they believe 

that there are either violations of OSHA 

standards or serious workplace hazards. 

How OSHA Can Help

For questions or to get information 

or advice, to report an emergency, 

report a fatality or catastrophe, or to 

file a confidential complaint, contact 

your nearest OSHA office, visit 

www.osha.gov or call our toll-free 

number at 1-800-321-OSHA (6742), 

TTY 1-877-889-5627. It’s confidential.

More Information

OSHA standards and regulations:

www.osha.gov/law-regs.html

OSHA publications:

www.osha.gov/publications

OSHA-approved state plans:

www.osha.gov/dcsp/osp

OSHA’s free On-site 

Consultation services:

www.osha.gov/consultation

Training resources:

www.osha.gov/dte

Help for Employers:

www.osha.gov/employers
DTSEM FF-3816 6/2015

Note: The described case was selected as being representative of improper work practices which likely contributed to a fatality from an 

incident. The incident prevention recommendations do not necessarily reflect the outcome of any legal aspects of this case. OSHA encourages 

your company or organization to duplicate and share this information.

This Fatal Facts is not an OSHA standard or regulation and it creates no new legal obligations. The recommendations contained herein are 

advisory in nature and are intended to assist employers in providing safe and healthful workplaces. The Occupational Safety and Health Act 

of 1970 (OSH Act) requires employers to comply with safety and health standards promulgated by OSHA or by an OSHA-approved state plan. 

The requirements of OSHA-approved state plans can be reviewed by selecting the state’s website at: www.osha.gov/dcsp/osp. The OSH Act’s 

General Duty Clause, Section 5(a)(1), requires employers to provide employees with a workplace free from recognized hazards likely to cause 

death or serious physical harm.

The host employer received several citations for 

violating OSHA standards in this incident, including: 

29 CFR 1917.27(b)(1) and 29 CFR 1917.49(c) & (d).

INCIDENT PREVENTION

After this incident, the host employer put into effect 

engineering and administrative controls for breaking up 

sugar clumps safely. The hopper was redesigned with 

a permanently affixed (welded) top screen. Workers 

were trained to break up sugar clumps by scraping the 

sugar across the screen using a material handling bucket 

while safely on the ground. A structure for attaching a 

horizontal lifeline was installed at the top of the hopper 

for the limited work activities requiring access. Safe work 

procedures for using the redesigned equipment were 

developed and incorporated into the workplace practices.

To prevent similar incidents, temporary staffing agencies 

and host employers have a responsibility to properly 

train all employees and ensure that appropriate safety 

measures are present in workplaces before work begins, 

for example:

1. Establish a clear understanding of the staffing agency 

and host employer’s respective roles in protecting 

workers. OSHA recommends that temporary 

staffing agencies and host employers specify in 

their contract their respective responsibilities for 

compliance with applicable OSHA standards (see 

OSHA’s Protecting Temporary Workers Page).

2. Staffing agencies should maintain frequent 

communication with their workers and host 

employers. 

3. Whenever feasible, before assigning work, staffing 

agencies should determine potential hazards at host 

employers’ workplaces, and ensure that the host 

employer would provide appropriate training and 

protective measures to temporary workers.

4. The host employer and staffing agency should each 

consider the hazards they are in a best position to 

prevent and work cooperatively to comply with 

OSHA standards. 

5. To protect workers from the hazards described in this 

incident, employers should:

a. Implement an effective safety and health 

program specific to the workplace. See 

OSHA’s Injury and Illness Prevention

Programs Safety and Health Topics Page

for details. 

b. Develop site-specific safe work procedures and 

provide training to workers in a language they 

understand. 

c. Eliminate the need to work on top of hoppers, if 

possible.

d. Use protective measures if it is not possible to 

eliminate the need to work on top of a sugar 

hopper. For example: 

i. Guard hopper and chute openings to 

prevent workers from falling or reaching 

into hoppers or chutes (e.g., install covers, 

29 CFR 1917.49(c)). 

ii. Equip hoppers with a safe walkway and 

means of access when workers are required 

to work on top (e.g., a fixed ladder to a work 

platform with guardrails, 29 CFR 1917.49(d)). 

iii. Protect workers from falling from the top of 

a hopper if work activities require access to 

the top by installing guardrails, providing 

fall protection equipment or using other 

appropriate equipment. When selecting 

a ladder, scissor lift, or similar type of 

equipment consider if it is suitable for the job, 

can be properly positioned, and safely used.

e. Provide all required training to workers, 

including temporary workers, in a language they 

understand. Include training on how to recognize 

and report unsafe conditions, necessary 

protective measures, how to properly use 

appropriate personal protective equipment, and 

how to safely complete assigned tasks. 

f. Provide training to all supervisors, including 

temporary workers hired as supervisors, on how 

to prevent incidents (29 CFR 1917.27(b)(1)).