A 36-year-old, Hispanic man died at a pork processing plant in central Iowa mid-winter of 2004. The victim had his feet entangled in an inclined, auger conveyor when it started. He was retrieving hardware or pieces of metal that had fallen into the auger during dismantling of conveying equipment and metal decking above the auger earlier that day and the day before. In an adjacent room the supervisor, who did not believe anyone was in or above the auger but was not able to see it, removed his lockout and turned on the main circuit breaker. The auger's on/off electric switch was mounted to the wall near the auger. The switch was in the "on" position so when the main circuit breaker was turned on the auger started immediately. A co-worker, who was also tasked with picking up metal debris from the work area, did not know how to turn the auger off so he ran outside the room calling for help. Another employee came into the rendering room where the auger was running and turned off the switch for the auger. The victim's legs were caught in the auger and he was face down, head down the incline, with his feet up the inclined auger. Rescue personnel arrived 10 minutes after the incident. Despite resuscitative efforts, the victim was pronounced dead at the scene 35 minutes later. RECOMMENDATIONS: 1. Equipment lockout/tagout procedures must be fully implemented, including checking the work area to ensure that all employees have been safely positioned or removed before removing lockout and notifying employees that lockout devices have been removed from energy sources. 2. Training should be provided to employees to ensure that the purpose and function of hazardous energy control of machines is understood and that they have the knowledge and skills required for safe application, usage, and removal of hazardous energy controls. 3. All employees should strive for clear communication with each other, and be aware that in hazardous situations language differences may result in misunderstanding of instructions.
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; Protective-measures; Equipment-operators; Industrial-environment; Industrial-hazards; Meat-handlers; Meat-packing-industry; Mechanical-cleaning; Mechanical-properties; Training; Animal-products-workers