INCIDENT HIGHLIGHTS

DATE: 

August 8, 2019

TIME:

~4:40 PM

VICTIMS: 27-year-old 

White male; 35-year-old 

White male

INDUSTRY/NAICS CODE:

Foundation, Structure, and 

Building Exterior 

Contractor/NAICS 238190

EMPLOYER: 

Aerial fabric design and 

installation

SAFETY & TRAINING:

Insufficiencies in supervisor 

oversight and training in 

safe boom lift operation.

SCENE: 

Hillside of music festival 

venue

LOCATION:

Oregon

EVENT TYPE:

Caught in/between

_____________________________ REPORT#: 2019OR01 REPORT DATE: June 29, 2023

Two Workers Killed in Boom Lift Rollover -

Oregon

_____________________________________________________________________

SUMMARY

On August 8th, 2019, two workers were operating a boom supported 

elevating work platform, also commonly referred to as a boom lift to

remove hardware and cables anchored to trees after a music festival.

They were working on a sloped hillside, with the boom extended and 

the counterweight on the downslope side. The boom lift tipped over 

and rolled down the hill with the two workers in the basket. Others 

witnessed the incident. Emergency responders pronounced both 

workers dead at the scene. Blunt-force trauma due to a fall from a 

moving object was ruled as the cause of death. READ THE FULL 

REPORT> (p.3) 

_________________________________________________________

CONTRIBUTING FACTORS

Key contributing factors identified in this investigation include:

• Deviation from equipment manufacturer's safe operation 

instructions:

o Disabling safety alarms on machinery.

o Operating a boom lift on a slope.

o Moving a boom lift with the telescopic boom extended.

• Insufficient worksite-specific communication to the workers and 

supervisors regarding the hazards of operating equipment on a 

sloping terrain. LEARN MORE> (p. 7)

______________________________________________________

RECOMMENDATIONS

Oregon FACE investigators concluded that, to help prevent similar 

occurrences, employers should:

• Ensure manufacturer instructions regarding equipment operation 

are followed through adequate supervision.

• Ensure boom lift operators know not to move the boom lift with the 

boom extended by providing training and supervision. 

• Maintain and regularly inspect equipment for its operational safety.

• Implement pre-task planning for jobs that include varying conditions 

or environments.

• Train employees to operate equipment safely. Verify training 

completion and check knowledge and skill level.

LEARN MORE> (p.8)
Page 2

Oregon Fatality Assessment and Control Evaluation Program

The Oregon Fatality Assessment and Control Evaluation (OR-FACE) Program is a project of the Oregon Institute of Occupational Health 

Sciences at Oregon Health & Science University (OHSU). OR-FACE is supported by a cooperative agreement with the National Institute for 

Occupational Safety and Health (NIOSH) (grant #U60OH012411) through the Occupational Public Health Program (OPHP) of the Public Health 

Division of the Oregon Health Authority. OR–FACE reports are for information, research, or occupational injury control only. Safety and health 

practices may have changed since the investigation was conducted and the report was completed. Persons needing regulatory compliance 

information should consult the appropriate regulatory agency.

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OR-FACE supports the prioritization of safety interventions using a hierarchy of safety controls, where 

top priorities are hazard elimination or substitution, followed by engineering controls, administrative 

controls (including training and work practices), and personal protective equipment.
INTRODUCTION

On August 8th, 2019, at an outdoor music festival venue, two workers were operating a Genie S-85 boom lift after the 

music festival had ended to remove the cables used to suspend fabric sails so that the area could be turned back over to 

the farm owners. The aerial fabric was part of an art installation near the stage and provided shade in the venue's 

audience seating area (See Image 1). The boom lift was on a hillside with the wheels parallel to the slope. The firststage boom arm was extended approximately 40 feet uphill, while the counterweight was oriented on the downhill side 

of the slope. Two safety alarms, a tilt hazard alarm, and a crush hazard alarm, had been disabled. The workers were 

moving the boom lift perpendicular to the hill slope with the boom arm extended when the boom lift tipped over in the 

downhill direction, catapulting the basket to the ground, where the two workers received fatal blunt force trauma 

injuries. Other workers on site attempted to render aid and called 911. Emergency responders arrived within 10 

minutes and declared the workers dead at the scene.

Image 1. Image of a fabric sails installation at the music festival venue. Note the cables attached to the sails are 

secured to trees in the background.

EMPLOYERS

The music festival had been occurring for over twenty years and primarily managed by volunteers until the prime 

employer was formed as a company ten years at the time of the incident. The prime employer contracts with subcontractors, including lighting, sound, video, and aerial fabric installation sub-contractors, to prepare, manage, and

break down music festival venues. The prime employer hired an event superintendent to coordinate sub-contractor 

activities and to order supplies and equipment requested by sub-contractors, such as boom lifts and scaffolding so that 

the sub-contractors could complete their assigned tasks. Prior to working for the prime employer, the superintendent 

had worked for six years with the second employer and was familiar with the fabric installation process, as well as many 

of the crew members working for the second employer on the day of the incident. The prime employer had overall 

responsibility for the supervision of sub-contractors to ensure work was completed safely and in accordance with design 

and operation plans. 

The second employer (subcontractor) is an Oregon-based aerial fabric design, fabrication and installation enterprise that 

had been in business for 13 years at the time of the incident and had 16 permanent employees. The subcontractor hired 

REPORT#: 2019OR05 v.3 Page 3 
temporary employees during music festival season, which is usually from late spring to early fall in Oregon. The 

subcontractor had a written contract with the prime employer for the aerial fabric installation and removal work. The 

second employer had been a previous sub-contractor at the music festival for ten years before the incident, performing 

the tasks of installing, maintaining, and removing fabric sails at the venue. 

At the music festival each year, the prime employer and subcontractor allowed a set number of volunteers to donate 

their time in exchange for free access to the music festival for themselves and their family or friends and food provided 

at the venue.

At the time of the incident, the subcontractor (aerial fabric design company) directly employed the younger decedent.

The older decedent was working for the subcontractor as a volunteer to connect/disconnect fabric tension cables to the 

trees at the west and north edge of the music venue, in exchange for free access to the music festival. The older 

decedent was acting in the capacity as lead on the two-man crew on the boom lift at the time of the incident.

WRITTEN SAFETY PROGRAMS and TRAINING

The subcontractor provided records of an operator training log where the topics covered included general operation of 

the boom lift, areas of the site with sloped terrain, general best practices, and a statement that employees should not 

drive with the boom extended on a slope. The subcontractor also had a fall protection plan signed by employees, 

including the younger decedent. 

There is some lack of clarity on the overall boom lift certification and training program provided by the employer. The 

younger decedent, that worked directly for the fabric sail installation employer, had a boom lift operator certification 

card in his possession at the time of the incident. The older decedent, hired as a volunteer, was a certified arborist with 

the state of Oregon, owner of a tree care service company, and was also certified as a boom lift operator. However, a

previous employee of the fabric sail installation company interviewed during the OR-OSHA investigation reported that 

the employer never verified his training on the boom lift, other than to ask if he had experience on the equipment. 

WORKER INFORMATION

The younger decedent (decedent 1), a 27-year-old male, had many years of experience as an arborist but was not 

licensed as an arborist in the state of Oregon. He had been directly employed by the second employer for three years 

prior to the incident, and represented the second employer as the liaison with fabric sail volunteers, which included the 

older decedent.

The older decedent (decedent 2), was a 35-year-old male and certified arborist in the state of Oregon with 

approximately 10 years of experience. He had worked as an independent contractor for the subcontractor for seven 

years, and specifically for three years as a volunteer worker at the music festival, prior to the incident. He is referred to 

as a volunteer because he was hired as an independent contractor with compensation provided as free admission to the 

music festival.

Although both decedents had experience working as arborists, they were not performing arborist work at the time of 

the incident. The work they were hired to do did not include any tree pruning/trimming or taking down trees for the 

music festival job site. However, their experience as arborists were skills that were desired by the employer for any work 

that required climbing trees to install or remove the rigging for the fabric sails. 

REPORT#: 2019OR05 V3 Page 4 
EQUIPMENT

The workers were using a Genie S-85 four-wheel drive telescopic boom lift manufactured in 2015. They were using this 

equipment to remove the hardware and cables that were attached to trees to suspend fabric sails. The equipment had 

been rented through a local equipment rental company. The last documented annual inspection for the boom lift 

occurred on March 29th, 2019.

The boom lift was being used on a sloped surface with the boom extended. The platform was positioned uphill with the 

counterweight positioned downhill. According to the equipment specifications, the maximum slope rating for the lift 

with the counterweight positioned downhill and the boom stowed is 30% or 17°. With the counterweight uphill and the 

boom stowed, the maximum slope rating is 45% or 24°. The operator's manual instructions indicate that the boom 

should only be raised or extended on a firm, level surface. The operator's manual was located in the platform 

compartment of the boom lift at the time of the incident. 

The Genie S-85 boom lift was equipped with a tilt alarm, which is an audible alarm that will sound if the lift exceeds its 

tilt angle. If the tilt alarm sounds when the platform is raised, the operator's manual recommends first retracting the 

boom and then lowering the platform. Extreme caution should be used if this occurs. At the time of the incident, the tilt 

alarm had been disabled by disconnecting the alarm cables. The lift guard contact alarm or crush protection system had 

also been disabled. This alarm uses an activation cable to stop boom movement and sound an alarm if the operator 

makes contact with the platform control panel. It is intended to protect the operator if pinned between an object and 

the platform. There was no indication that pre-operation inspections of the equipment were being performed, as 

required by the manufacturer.

The workers were using fall protection as required by the equipment manufacturer. They were each wearing a harness 

and lanyard and were connected to the anchor point provided on the lift platform.

WEATHER

On the day of the incident, the weather was clear and sunny, with a WNW wind of 10 mph and no precipitation. The 

temperature was about 77°F at the time of the incident. The wind direction and speed cannot be ruled out as a 

contributing factors in this incident (Weather Underground, 2019). 

INCIDENT SCENE

The incident occurred on a sloping hillside of a private farm field bordered by tall trees on the west and north side (See 

Image 2). The trees are used to anchor cables that suspend fabric over the audience seating area, the event stage, and

other event areas. The highest elevation of the field is on the west side, sloping downward approximately 10° to the 

east, where it flattens out, creating a bowl shape. The field is made available as a music venue for about two weeks 

during the summer, including set-up and tear-down of equipment and effects. 

Page 5 REPORT#: 2019OR05 V3 
Image 2. Side and top view of the incident scene. Wheels on boom lift 

are parallel to the dirt road to the west. Not to scale.

INVESTIGATION

Site prep for the music festival began on July 15th, 2019. The employer was contracted by the music venue management 

company (VMC) for site preparation. The employer provided the VMC with a list of vehicles and equipment needed to 

complete the site prep, and the VMC contracted with the vehicle and equipment rental companies. Decedent 1 was

directly employed by the employer and was told to work with decedent 2, a volunteer hired by the employer, to install 

cables that would suspend the fabric sails above the stage and seating area. The two workers had worked together 

before at the same music festival in previous years and were friends. 

The music festival took place from August 1st through August 4th, 2019. After the music festival, the two workers were 

tasked with removing the cables and hardware attached to trees that suspended the fabric sails. They were among the 

last trades to remove their items from the venue. 

The boom lift was a Genie S-85 four-wheel drive diesel engine and a straight boom. Prior to the incident, the boom lift 

was being operated on the west side of the hill near the tree line and just east (below) a dirt road. The wheels of the 

boom lift were parallel to the dirt road. The first stage of the boom was extended approximately 40 feet westward 

toward the trees. The basket where the operators were standing was approximately 60 feet in the air. The 

counterweight was on the downhill slope of this hillside. Just before the incident, operators (decedents) moved the 

boom lift to the north, extending the boom. 

REPORT#: 2019OR05 V3 Page 6 
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The wheels on the west side lifted off the ground, rolling the boom lift eastward down the hill, where it came to rest 

(See Image 3). 

Image 3. Incident Scene. Location and orientation of boom lift postincident. Still image taken from video recorded by the OR-OSHA 

Safety Compliance Officer. 

According to documentation and interviews during the OR-OSHA investigation, the employer management 

representatives were present for the installation of the fabric sails, but were not onsite during the breakdown process 

after the festival. During the installation process, there is evidence that they communicated with employees about using 

the boom lift on sloped terrain with the counterweight uphill, and they also communicated not to drive with the boom 

elevated. However, there was a lack of evidence that this same information was communicated during the breakdown 

process.

The OR-OSHA investigation interviews with employees, previous employees, and volunteers indicated that the practice 

of disabling the tilt alarm on lifts had been going on since at least 2012. The management of the fabric sail installation 

company was familiar with the layout of the farm and knew that it included uneven terrain. They stated that the alarms 

were going off during the installation process and were aware of the practice of disabling alarms. A volunteer for this 

company stated that the alarms were disabled because they made communicating over the alarm sound difficult. A 

previous employee also stated that she left the company because of issues with employees disabling the alarms on the 

boom lifts. Another equipment rental company used in previous years reported that they stopped renting equipment 

for this event in 2016 because they found an alarm disabled and an illegal substance on the returned rental equipment. 

CAUSE OF DEATH 

According to the Medical Examiner report, the cause of death was blunt force trauma.

CONTRIBUTING FACTORS 

The unrecognized hazards or inadequately controlled exposures that contributed to this incident include:

• Accepted practices of disregarding the equipment manufacturer's safe operation instructions by:

▪ Operating the boom lift on a slope.

▪ Moving the boom lift while the telescopic boom arm is extended.

▪ Disabling safety alarms.
REPORT#: 2019OR05 V3

Page 8

• Insufficient worksite-specific communication to the worker and supervision regarding the hazards of 

operating equipment on a sloping terrain.

Occupational injuries and fatalities are typically the result of one or more immediate contributing factors or key 

events that are part of a larger context or sequence of events. While the direct cause of death was being crushed 

when the extended boom lift rolled over and the basket holding the two decedents struck the ground with force, 

there were several indirect or upstream contributing factors that led to the employees being exposed to the fatal 

hazard. In addition to exposure to mechanical, chemical, and environmental hazards, there were several training 

insufficiencies. Recognizing and controlling exposure to these hazards may have prevented this tragedy.

RECOMMENDATIONS/DISCUSSION 

• Recommendation #1: Ensure manufacturer instructions regarding equipment operation are followed, 

including providing adequate supervision.

Discussion: The employer should identify and mitigate workplace hazards and ensure employees (especially 

employees who are new to a worksite) have adequate training on limiting exposure to hazards associated with 

each task they perform. Training must be provided by a competent person who can instruct employees on how 

to recognize hazards and ways to prevent or limit exposure. In addition to providing training, employers should 

perform knowledge or task demonstration checks to verify employees have understood the training, can

recognize worksites and task hazards (especially new worksites and tasks), and perform tasks safely. Knowledge 

and skill verification should include the employee demonstrating the new or familiar task under supervision in a 

new work site. Employers should also ensure employees know they have the right to stop work if they feel it has 

become dangerous (29 CFR 1977.12).

In this incident, the worksite included sloping terrain, and the equipment instruction manual specified not to use 

the lift on sloping terrain with wheels parallel to the slope. In addition, the equipment instruction manual 

specified that the boom should only be extended when the equipment is on a firm level surface. 

The sloping terrain of the hillside was known as an occupational hazard of this particular worksite. However, the 

worksite was not assessed for hazards by a competent person, nor were the hazards mitigated by the employer 

through policies and procedures. Further, the weather may have posed an additional potential hazard of the 

wind exacerbating the instability of the extended boom lift. The primary responsibility belongs with the 

employer to assess and suspend operations when weather conditions might require it. The employer should also 

ensure employees understand they can stop work on the task and contact a supervisor if the employee feels the 

working conditions are, or have become, unsafe.

• Recommendation #2: Do not move the boom lift equipment with the boom extended.

Discussion: Moving the boom lift with the boom extended destabilizes the equipment, especially if operating the 

boom lift on sloping ground. The Oregon Administrative Rule (OAR) for the Construction Industry (Division 3), 

incorporating federal OSHA standard on Aerial Lifts by reference, states that "An aerial lift truck shall not be 

moved when the boom is elevated in a working position with men in the basket, except for equipment which is 

specifically designed for this type of operation in accordance with the provisions of paragraphs (a)(1) and (2) of 

this section". (OAR 437-003, Section L, adopting 1926.453(b)(2)(viii) by reference).
REPORT#: 2019OR05 V3

Page 9

The employees using the boom lift should have been trained on the safe operation of the equipment, including 

not moving the lift with the boom extended. Additional oversight or supervision of the job site during the 

breakdown process could have also identified this unsafe practice.

• Recommendation #3: Maintain and regularly inspect equipment for its operational safety.

Discussion: The condition of any vehicle or equipment is a critical factor for worker safety. The National Institute for 

Occupational Safety and Health (NIOSH) recommends establishing "operating and maintenance policies that follow 

manufacturer's terrain guidelines" (NIOSH, 2012). Routine maintenance schedules, lockout/tagout procedures for 

vehicles and equipment, and maintenance/repair records are part of the recommended practices for employers to 

ensure a safe working environment. 

Following the equipment manufacturer's instructions on safe use is another critical factor of operator safety. In this 

incident, the employer did not have a written procedure for reporting issues with vehicles/equipment. Employers 

should also have rules or other means in place to prevent the removal or disabling of any safety device associated with 

equipment (OAR 437-001-0760(1)(b)(D)).

In the current case, the tilt alarm and crush alarm had been disabled at some time prior to the incident. The 

investigation interviews provide evidence that this may have been a common practice at the particular worksite. Preoperation inspections were not performed to verify the function of alarms or to check for other maintenance issues.

• Recommendation #4: Implement pre-task planning to identify site-specific safety hazards and communicate 

appropriate control plans.

Discussion: The goal of a pre-task plan is to meet with employees prior to starting work in order to review the 

tasks to be completed and identify any hazards or potential hazards. This process is similar to a Job Hazard 

Analysis, where each step in the process is assessed for hazards, and controls are implemented. While it is 

similar, pre-task planning is often used in the construction industry or in work where conditions and tasks 

change. In these types of work environments, hazards or hazardous conditions would need to be assessed more 

frequently. When hazards are identified, then a plan is developed and controls implemented to protect 

employees from the hazards. Pre-task meetings should also include time for the participation of workers to ask 

questions or bring up concerns. 

In this situation, a pre-task plan should have included surveillance of the terrain and weather and the 

development of a plan to take these conditions into account. It should have also included an assessment of the 

appropriate equipment for the tasks. While the sub-contractor did provide Job Hazard Analysis checklists for the 

days of set-up prior to the festival, the process failed to control for the hazards encountered adequately. An 

adequate pre-task plan could have identified the need for appropriate equipment for this particular task. Because 

the work needed to take place on sloped terrain and the tilt alarms had been sounding, this is an indication that 

the Genie S-85 was not the appropriate equipment for this particular task in this location. Other equipment 

should have been considered for this work, including an aerial boom lift with outriggers for stability. 

• Recommendation #5: Train employees to operate equipment safely. Verify training completion and check 

knowledge and skill level.

Discussion: Employers are responsible for ensuring that employees know how to operate equipment while on the job 

safely. Employers must also maintain training records and renew training at least annually, or when it is warranted, due

to equipment upgrade/replacement or when the equipment is used for the first time in a new area. 
To operate equipment in Oregon, employers are required to:

1) "... instruct each employee in the recognition and avoidance of unsafe conditions and the regulations 

applicable to his work environment to control or eliminate any hazards or other exposure to illness or 

injury." (OAR 437-003, Subdivision C, adopting 1926.21, by reference).

2) "See that workers are properly instructed and supervised in the safe operation of any machinery, tools, 

equipment, process, or practice that they are authorized to use or apply" (OAR 437-001-0760 (1)(a); and

3) "[ensure that] Only trained and authorized employees may operate any vehicle." (OAR 437-003-

3410(3)(a)(B)). Employers are required to provide training to employees in a language they understand so 

they know how to safely operate equipment. Employers should also have written procedures in place to 

confirm the knowledge transfer, skill, and ability of employees who are new to a task or worksite.

4) When specifically operating a boom aerial work platform, the operating manual must be kept with the 

equipment, and employees must follow operating and maintenance instructions and recommendations of 

the manufacturer (OAR 437-003-0073(1)).

Because of the complex nature of multiemployer worksites, there is also the need to specify the details of 

providing training to employees and volunteers. The responsibility of training should be clearly outlined with the 

names or positions that are responsible for providing training and the specifics of verification of the operator's 

knowledge and skills.

ADDITIONAL RESOURCES 

Oregon Institute of Occupational Health Sciences Resource Directory. https://apps.ohsu.edu/oregon-instituteoccupational-health-sciences/resources/

Oregon Healthy Workforce Center. https://www.ohsu.edu/oregon-healthy-workforce-center.

DISCLAIMER

Mention of any company or product does not constitute endorsement by Oregon FACE program (OR-FACE) or the 

National Institute for Occupational Safety and Health (NIOSH). In addition, citations to websites external to OR-FACE or 

NIOSH do not constitute an endorsement of the sponsoring organizations or their programs or products. Furthermore, 

OR-FACE or NIOSH is not responsible for the content of these websites. All web addresses referenced in this document 

were accessible as of the publication date.

REPORT#: 2019OR05 V3 Page 10
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Page 11

REFERENCES

29 CFR 1977.12 Discrimination Against Employees Exercising Rights Under the Williams Steiger Occupational Safety and 

Health Act of 1970. https://www.osha.gov/laws-regs/regulations/standardnumber/1977/1977.12

NIOSH, 2012. All-Terrain Vehicle (ATV) Safety at Work. National Institute for Occupational Health and Safety publication

No. 2012-167. https://www.cdc.gov/niosh/docs/2012-167/pdfs/2012-167.pdf. 

OAR 437-001-0760 (1)(a). Rules for All Workplaces: Employers' Responsibilities. Oregon Administrative Rules for 

General Administration, Order 3-2019. https://osha.oregon.gov/OSHARules/div1/437-001-0760.pdf

OAR 437-003-0073(1). Boom supported elevating work platforms. https://oregon.public.law/rules/oar_437-003-0073. 

OAR 437-003, Subdivision C, adopting 1926.21 by reference. Safety Training and Education. Oregon Administrative 

Rules for General Administration, Order 3-2019. https://osha.oregon.gov/OSHARules/div3/div3.pdf

OAR 437-003-3410(3)(a)(B). Agricultural, Commercial and Industrial Vehicles. https://oregon.public.law/rules/oar_437-

004-3410

OSHA, 2002. Job Hazard Analysis. Occupational Safety and Health Administration, Publication 3071.

https://www.osha.gov/sites/default/files/publications/osha3071.pdf. 

Weather Underground (2019). https://www.wunderground.com/history.

FACE INVESTIGATION INFORMATION

This investigation was conducted by Barbara Hanley, MPH, PhD, Research Associate, Fatality Investigations Team,

Oregon FACE (OR-FACE) at Oregon Institute of Occupational Health Sciences at Oregon Health and Science University 

(OHSU). The report was peer-reviewed by Jackie Boyd, OR-FACE Project Coordinator, Dr. David Hurtado, OR-FACE 

Principal Investigator, and Rachel Madjlesi, OR-FACE Fatality Investigator. 

ACKNOWLEDGEMEMENT

The OR-FACE Program would like to acknowledge the staff of the Oregon Department of Consumer and Business 

Servicesfor providing assistance and information for this investigation. The Oregon FACE Program would also like to 

acknowledge Renée Stapleton and Byron Snapp for their review of the investigation report.