On May 5, 2005, a 55-year-old experienced millwright maintenance mechanic was killed while inspecting repairs to a building materials setting machine. New parts had been installed a week earlier. The repaired machine, commonly called a "stacker," had been operating well for 4 days prior to the incident. On the morning of the incident, the stacker was in operation for 1 hour, and then put into idle mode for a few minutes while the operator added more unfired product by hand. While the stacker was idling, the mechanic entered a barricaded, posted area under the stacker to inspect the stacker's alignment chain. The mechanic failed to lockout the machine and did not notify the operator. The mechanic was apparently leaning over a support beam to inspect the chain alignment when the operator took the machine out of idle and resumed operation. The stacker's traveling bar, located under the deck, evidently crushed the mechanic's head against the support beam. The victim was discovered within minutes by the plant manager. Local law enforcement and medical crews arrived shortly thereafter, and the victim was declared dead at the scene. View of stacker shows barricaded undercarriage where incident occurred. Recommendations: 1. Employers should ensure that all machine moving parts and pinch point areas are fully enclosed or fully barricaded from access, and that machine guards are properly installed. 2. Employers should develop, implement, and enforce a comprehensive hazardous energy program. 3. Interlock devices should be installed to automatically shut down energy when safety gates on equipment are opened. 4. Alarm systems should warn whenever machinery is activated.
Region-10; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-practices; Safety-education; Safety-equipment; Safety-measures; Equipment-operators; Warning-devices; Warning-systems; Machine-guarding; Equipment-design