On May 3, 2004, a 49 year-old male machinist, who was employed by a machine shop, sustained fatal injuries as a result of being struck by a 1,800-pound steel spool that fell from a hydraulic lift table at a tissue paper plant. The hydraulic lift table was part of a section of a paper machine called a core extractor, or spool extractor. The machine shop had manufactured, assembled, and installed the spool extractor for the tissue paper company. On the day of the incident, a crew from the machine shop, including the victim, performed maintenance on the spool extractor. When the machine shop crew arrived at the extractor area, the spool was resting on two tracks. At the end of each track, there was a stopping mechanism (a stopper) to prevent the spool from falling off the track. In preparing to replace a damaged hydraulic hose under the table, the machine shop staff raised the lift table that was underneath the spool. The damaged hose was the main feed hose that pressurized the tilter, a device mounted on top of the lift platform for holding and stabilizing the spool. As the lift table was raised above the tracks, it raised the spool approximately 11 3/4 inches above the tracks and held it with the tilter. The hydraulic lift manufacturer required that all loads be removed and the lift blocked and supported by a maintenance "leg" prior to performing maintenance or entering the area under the platform. The machine shop staff neither removed the spool from the lift table nor lowered the lift platform to rest on the leg during maintenance. At approximately 1:45 p.m., a co-worker of the victim went underneath the lift to change the damaged hose. He used a wrench to loosen the hose and hydraulic fluid started leaking out. The tilter apparently lost its hydraulic pressure due to the release of the hose and the spool rolled off the tilter and struck the victim. According to the co-worker, the victim was adjacent to the lift, either squatting or bending towards it at the time of the incident. The co-worker did not see the spool strike the victim; he heard the spool hit the ground and saw the victim underneath the spool extractor. The co-worker yelled for help and plant personnel responded to the scene. They immediately lifted the spool off the victim with an overhead crane and called 911. Both the company nurse and the city paramedics responded to the scene within minutes. The victim was transported to a local hospital where he was pronounced dead. New York State Fatality Assessment and Control Evaluation (NY FACE) investigators concluded that to help prevent similar incidents from occurring, employers should: 1. Develop and enforce safety policies or procedures that require workers to remove loads before beginning maintenance activities; 2. Provide employee training and ensure workers follow manufacturer’s requirements and recommendations when operating or performing maintenance on a machine; and 3. Ensure that all energy control devices are securely locked and tagged before allowing workers to perform maintenance on a machine. Additionally, the hydraulic lift table manufacturer should: 4. Consider lengthening the maintenance leg, if feasible, to increase the amount of working space available during machine maintenance.
Region-2; 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; Training; Machine-shop-workers; Machine-tools; Machinists; Paper-manufacturing-industry