MCRD Refused to Bolt Down Soda Machines : Marine Killed 8 Months After Bottler Was Denied Access to Recruit Depot

A soft-drink machine that toppled onto and killed a 19-year-old Marine in San Diego last July was not bolted down because mid-level officials at the Marine Corps Recruit Depot had refused eight months earlier to do so, The Times has learned from documents obtained through the U. S. Freedom of Information Act.

Although an investigative report appears to lay blame for the accident on the victim, who had been drinking, the report also shows that officials at the base were aware for nearly two years before the fatality that Marines were tipping the vending machines.

Two vending machine tip-overs injured Marines at the depot in 1986, and a year later the Navy began bolting down its machines nationwide. Navy and Marine publications during that time also carried warnings about the problem.

Nonetheless, the recruit depot’s safety committee discussed and then set aside the idea of bolting down the machines in November, 1986, because of concern about damaging the 1920s-era buildings at the base, the investigation by Marine 1st Lt. Mark J. Griffith concluded.

Then, in late 1987, eight months before the fatal accident, “an unknown individual or individuals” refused to allow workers from the vending company to bolt down the machines, Griffith’s report says.

Representatives of Pepsi Cola Bottling Co. of San Diego were turned away “because of the fact that the historical value of the buildings prevented them from anchoring any type of permanent bolts or studs into the floor or to the walls,” according to a statement to the investigator by Lt. John T. Wolfe, assistant merchandise manager for the Marine Corps exchange system at the MCRD.

The decision was made despite the fact that the buildings’ interiors have been updated into offices with carpets, ceiling tiles and other changes since their construction in 1921.

Griffith said in his report that the lengthy interval since the denial prevented him from determining who was responsible for the decision not to bolt the machines. Disciplinary action was “neither warranted nor contemplated,” he wrote.

However, even a week after the fatal accident, permission to bolt the machines was again denied by the depot’s facilities division, and was granted only after the commanding general was notified of the denial by investigators, said Maj. Jerry Broeckert, public affairs officer at the depot.

On July 31, 1988, nearly two years after the base safety committee first rejected the idea of securing the machines, Pvt. Michael R. Carlson lay groaning beneath a half-ton soft-drink machine in an MCRD recreation room. The machine had fallen onto him after he tipped it forward to coax out a soft-drink can.

Carlson died on the operating table two hours later at the Navy Hospital in San Diego. Liver lacerations caused massive internal bleeding, according to the accident investigation.

The accident added Carlson to the list of people, many of them in the military, who have been crushed by falling machines during the past several years. A U. S. Army physician reported 47 accidents, 11 of them fatal, on overseas bases since 1985. In the United States, the Consumer Product Safety Commission knew of seven fatalities and 10 injuries by April, 1988, but it regards the figures as incomplete.

Teen-agers and college students are other likely victims. A year ago, a 15-year-old boy suffered two broken legs when a machine fell on him at Palomar Community College.

The commission announced in April that Vendo Corp. of Fresno had agreed to modify the model of soft-drink machines whose design appeared to have contributed to the spate of accidents. In February, the secretary of the Navy ordered that by the end of the month all soft-drink machines on Navy property would have to be secured to prevent tipping.

Even before that order, however, the Navy and the Marines were aware of the nationwide problem.

The Navy Safety Center warned of the problem in a 1986 publication. In November, 1987, the San Diego naval command sent out a notice that, because of similar incidents at military bases nationwide, the Navy Exchange Service had ordered all its soda machines secured. The exchange service manages food and other retail services for the Navy, but not the Marines.

The investigation of Carlson’s death emphasizes that the November message about securing the machines came from Commander Naval Base San Diego, whose messages are “not controlling over the Marine Corps Recruit Depot.” The Marine Corps is under a separate command structure from the rest of the Navy.

The message was received by the commanding general’s office at the MCRD and was treated as an information message and sent on to all commanders and staff members, said Broeckert, the depot’s public affairs officer.

Asked why no action was taken to solve a known safety problem, Broeckert said, “A lot of times it takes a tragedy before something happens.”

He denied that the communique’s underlying concerns were ignored because the message was not binding on the Marines, or that there was a lack of urgency concerning the problem.

“We teach two things from the beginning: accomplishment of the mission and safety of the troops,” Broeckert said.

Nevertheless, when the contractor that supplies soda machines for both San Diego Navy bases and the MCRD tried to address the safety problem, it got nowhere. Using the San Diego naval commander’s order as authorization, Pepsi Cola Bottling Co. sent workers to the recruit depot in late November or early December, 1987, to secure the machines, according to the investigation report.

The workers were turned away by unidentified Marine officials because of concerns about damaging the buildings’ historical value, the report says.

Broeckert said that, while it is now apparent that property damage was being given too much weight over safety, base officials were merely trying to protect federal property. He compared it to how a homeowner might react if the supplier of a home water cooler suddenly showed up with a drill ready to fasten the cooler to the kitchen floor.

“You’d probably ask some questions. That’s probably the process that went on here,” Broeckert said. “Obviously, that wasn’t the right answer, because since then we did it . . . based on safety concerns.”

The original buildings at the MCRD were built in 1921 and designed in Spanish colonial style by the same architect, Bertram Goodhue, who designed many of the distinctive buildings in Balboa Park, said George Kordela, curator of the MCRD Command Museum.

They were followed by a World War II building boom of less significant structures, and then others, he said. But in many cases, an effort was made to match the style of the original, giving the depot’s mustard-color buildings a distinctive, unified look of red tile roofs, decorative arches and stone adornments.

Federal law requires military installations to consult with state authorities whenever they plan modifications affecting the historic characteristics of a building, said Dorene Clement, a state historian who works with that program in California. However, if a building’s interior already has been extensively changed, further changes there are not considered to affect its historical characteristics, she said.

Within two weeks of the accident that killed Carlson, Pepsi Cola renewed its offer to bolt down the machines at the MCRD, the investigation found. “The offer from Pepsi Cola to secure its machines to the decks and/or bulkheads should be accepted,” the report says.

After yet another denial of permission by the facilities division, all machines were bolted down within two months of Carlson’s death, Broeckert said. The bolting was done at the order of the commanding general at the time, Maj. Gen. Donald Fulham, he said.

The investigative report’s account of Carlson’s accident paints a picture of a troubled, homesick young Marine who was within a month of being discharged from the service because of adjustment problems.

Witnesses said Carlson, of Ishpeming, Mich., drank too much at a Camp Pendleton beach picnic the Sunday he was killed. Other Marines had to put him into his bunk after the group arrived back at MCRD about 7:30 p.m., the investigative report says.

Carlson napped for about an hour, then asked a friend to go with him to the depot’s bowling alley to get a pack of cigarettes.

That was the last anyone saw of Carlson until a loud crash awoke Pfc. John G. Zilbert as he lay sleeping on a couch in the Building 2 West recreation room. It was about 8:40 p.m., and Zilbert saw that the soft-drink machine had toppled over.

Zilbert and two Marines who were passing by the room rushed over to help.

“I jumped up and turned around, and saw someone had apparently pulled the Pepsi machine over and it had landed on top of him,” Zilbert told the Navy’s investigator. “ . . . I could see his chest, approximately from his shoulders up, that was not under the machine. He was saying he couldn’t breathe, for us to get it, the machine, off, that he was hurting, and that it, the machine, took his money. He repeated that several times while we were lifting the machine off of him and while we . . . were waiting for the ambulance.”

Thirty minutes later, Carlson was at the Navy Hospital in Balboa Park, still conscious and talking but complaining of severe abdominal pain, witnesses said. Within minutes, however, doctors had to start cardiopulmonary resuscitation and give him seven pints of blood because of internal bleeding.

He was taken to the operating room 48 minutes after arriving at the hospital, and died there 36 minutes later.

Before the accident, it had become common knowledge at the depot that, if the machines were tipped and rocked, one could receive a soft drink without paying, Marines at the depot told the accident investigator. This was also used as a solution when coins were inserted but the machine failed to dispense a soda.

It was that trait of 111,000 Vendo machines made between 1982 and 1985 that led to the Consumer Product Safety Commission action in April. Nationwide, the machines are to be equipped internally with a plastic device that makes free sodas impossible. Warning stickers are also to be placed on the outside of the machines. At the MCRD, all machines are bolted to the floor, but they bear no safety stickers.

At the time of the accident, some doctors within San Diego County’s system of trauma hospitals expressed concern that Carlson’s life could have been saved if he had been taken to a civilian trauma hospital for specialized emergency care. Trauma centers at UC San Diego Medical Center and Mercy Hospital and Medical Center are closer to the Marine depot than the Navy hospital.

However, Carlson’s injuries were so severe that he would have had only a slightly better chance of survival at a trauma center, said Dr. Steven Shackford, trauma center director at UCSD Medical Center. Shackford, a former Navy surgeon, said he had reviewed the medical details of the Carlson case at the Navy’s request.

Currently, San Diego military personnel who have sustained traumatic injuries go to the Navy Hospital, unless the accidents occur off base. However, Marines who are seriously injured at Camp Pendleton frequently are airlifted to San Diego trauma units instead of the Navy Hospital, Shackford said.