On February 9, 1998, a 40-year-old male employee died while working at a paper mill. The employee was working at the winder station. The winder station consists of a spool-like machine on which the paper is wound. One complete roll of paper was processed. When inserting the paper for the next roll, the victim noticed that the paper was not winding properly, and entered the pit below the winder. Because of the large size of the equipment, components may be started up or turned off while machine tenders are out of sight of the operator. In this case, another employee, unaware that the victim entered the pit, assumed there was a problem and went to the back of the winder to turn off the lockout switch. When the lockout switch was turned off, a safety plate came down to prevent access, and the victim was pinned against the beam when the safety plate came down. The employee then went around the other side of the winder to enter the pit and noticed the victim was in the pit. The employee called for help, and the victim was taken to a local hospital, where he was pronounced dead. Recommendations based on our investigation are as follows: 1. Ensure that employees are trained in the lockout / tagout procedure. 2. Ensure that pit areas are adequately marked. The grated floor grid of the pit area should be painted with yellow stripes, adequate lighting installed, and signage placed outside the pit area. 3. Provide training and documentation on specific lockout procedures. A clear understanding of procedures should be provided in the training.
Region-7; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-areas; Work-performance; Work-practices; Safety-education; Safety-equipment; Safety-measures; Safety-monitoring; Protective-measures; Machine-guarding; Machine-operation; Machine-operators; Paper-mills; Paper-manufacturing-industry; Paper-milling; Training