Fatality Assessment and Control Evaluation (FACE) Program
Seventeen-Year-Old Bagger at Retail Grocery Store Suffers Amputation While Operating a Meat Grinder - Pennsylvania
On September 12, 2000, a 17-year-old bagger (the victim) at a retail grocery store suffered amputation of the right arm as a result of being caught in an operating meat grinder. The victim had been working in the family-owned store after school hours. On the day of the incident, a customer asked him to get some ground beef. There was none available, and no one working in the meat room. The youth decided to prepare the ground beef himself and went to the meat room to process the beef through the meat grinder. While he was operating the grinder, some of the meat became stuck in the meat grinder bowl. The youth removed the feed pan, reached with his right hand into the bowl and pushed the meat down into the grinder's worm.1 When meat fed from the bowl, the worm caught his hand and fed it into the grinder's barrel, amputating his hand and part of his lower right arm. Coworkers called 911 and emergency medical personnel responded within 5 to 10 minutes.
NIOSH investigators concluded that, to help prevent similar occurrences, employers should
Additionally, manufacturers of power-driven meat-processing equipment should
On September 12, 2000, a 17-year-old bagger (the victim) at a retail grocery store suffered amputation of the right arm as a result of being caught in a meat grinder while operating the machine (Photo 1). On January 10, 2001, the U.S. Department of Labor, Wage and Hour Division notified NIOSH's Division of Safety Research (DSR) of the occurrence. On March 5, 2001, a DSR safety engineer met with the Wage and Hour investigator, reviewed the case file, and discussed the case. On March 6, 2001, the safety engineer visited the grocery store, examined the meat grinder, and interviewed the meat department manager and the company's bookkeeper. Photographs and measurements of the meat grinder were taken. On March 6, 2001, the safety engineer met with the U.S. Occupational Safety and Health Administration (OSHA) compliance officer assigned to the case and discussed the case.
The employer was a family-owned neighborhood grocery store located in a large city. The store had opened for business in 1992 and employed 10 adult workers. The victim was the only employee under the age of 18. The employer had no written safety and training policy. Three days before the incident the youth had begun working after school. He was assigned to bag groceries at the front of the store and had been given on-the-job training for this task. Because he was not assigned to operate the meat grinder or other meat processing machines, he had not been instructed about their operation or potential hazards. However, since working at the store, he had socialized with the meat-room workers during breaks and idle periods, and it is likely that he had observed adult coworkers operating the meat grinder.
This was the first injury that had occurred at the store.
There were no eyewitnesses to the incident, and when interviewed by the Wage and Hour investigator, the youth could not remember the details of the incident. For this reason, the exact sequence of events is not known. However, during the site visit on March 6, 2001, the meat grinder was examined by the safety engineer, assisted by the meat department manager. Measurements and tests were conducted in an effort to identify a likely sequence of events to explain the manner of energy transfer between the meat grinder and the victim.
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The meat grinder involved in this incident had been previously owned and was purchased by the employer when the store opened. The age of the machine was not known. The machine was powered by a 5-horsepower electric motor that drove a worm through a geared transmission. The motor and transmission were enclosed in an equipment cabinet with the grinder assembly (a cylinder and bowl housing, a grinder plate and locking ring, and the worm) mounted on one end. The worm, mounted under the bowl, rotates inside the grinder cylinder (Photo 2a and Photo 2b). Meat fed manually into the bowl from the feed pan drops onto the rotating worm, which forces it through the cylinder, past a set of four knife blades mounted on the end of the worm, and through the grinder plate at the end of the cylinder. A stuffer is supplied with the machine to assist in feeding the meat down into the bowl.
The machine is equipped with several safety features designed to protect an operator from becoming caught by the worm. The feed pan is equipped with a permanently attached aluminum bowl guard covering the feed pan bowl opening (Photo 3). There is a safety interlock switch mounted between the top of the equipment cabinet and the bottom of the feed pan that interrupts power to the motor when the pan is removed (Photo 4). The motor cannot be restarted until the feed pan is replaced and the interlock switch paddle depressed. The feed pan is secured to the top of the equipment cabinet by a hook at the end of the cabinet opposite the grinder assembly and two toggle latches just above the grinder assembly. A push-button-operated start/stop switch is located on the side of the equipment cabinet. This switch type and its location minimize the likelihood of inadvertent startup by persons leaning or bumping against it.
On the day of the incident, the victim had been at work for several hours after school dismissal. He had gone about his assigned duties as a bagger. Shortly before 4:30 p.m., he was walking from the front of the store to the rear, when a customer stopped him and requested assistance in obtaining some ground beef. To accommodate the customer's request, the youth went to the meat room which was unoccupied because the meat department manager had left the store to deliver groceries to a customer. The store's supply of ground beef had been depleted so the youth started the meat grinder to process more. While he was grinding the meat, some of it stuck in the feed bowl, just above the worm. As previously stated, the exact sequence of events after this point could not be established. However, an evaluation of the machine's physical and operational characteristics indicate that the youth removed the feed pan and pushed the stuck meat down into the bowl with his hand. At this point, one of the following occurred (see Appendix):
When his fingers went below the bottom of the bowl his hand was caught by the worm and fed into the cylinder, amputating his arm below the elbow near his wrist. Coworkers heard his cries for help and called 911. EMS responded within 5 to 10 minutes and the youth was transported to a local trauma center.
As a result of the incident, the victim suffered amputation of the lower right arm.
Recommendation #1: Employers should ensure that workers are trained to recognize the hazard of accessing the internal components of operating or energized machinery.
Discussion: Because the youth was not assigned to operate the machine or perform work tasks in the meat room, he had not received instruction in the hazards of operating the meat grinder. His assigned task was to bag groceries at the front of the market. However, he had socialized with the meat room employees during breaks and may have observed other workers grinding meat or disassembling the machine for cleaning at the end of the day. Further, the operation of the grinder is not complicated from the standpoint of starting and stopping the machine, feeding meat through the bowl guard, and collecting the ground meat as it is discharged from the grinder plate. In some respects, the machine is nothing more than a large kitchen appliance and the basic operating procedure is intuitive. However, what is not so apparent is the risk of being caught by the grinder worm if the worker reaches into the bowl while the machine components are still in motion. Even though workers may not be assigned to operate certain types of equipment, training them to recognize hazards associated with the equipment's operation could further reduce their risk of injury from contact with the machine's components.
Photo 5. Typical Method of Locking Out Line Cord Plug
The FACE investigation project is the cornerstone of the overall NIOSH program to prevent occupational fatalities. The objectives for this effort include the investigation of occupational fatalities to assess and characterize the circumstances of these events in order to develop succinct descriptive and evaluative reports for distribution to occupational safety and health groups across the country. This work is being conducted by the FACE investigation team. It is expected that the reports alone will have a major impact by better defining the causal factors behind occupational fatalities, calling national attention to the problem, and providing insights into the prevention efforts that are needed. However, the program does not determine fault or place blame on companies or individual workers.