Rubber equipment operator died after his head was caught between bars of operating machinery, Oregon
Oregon Case Report: 18OR029
Release Date: June 2019
On August 23, 2018, a 23-year-old male Caucasian rubber cutter was found caught between two bars of a festoon rubber processing line (cooling line). The event was unwitnessed; however, circumstances suggested that the employee entered the festoon area to retrieve and redirect a rubber strip on a cooling bar that had passed the point where it should have fed onto a conveyor. It is believed that the worker raised his head between the moving cooling bars, and that the bars then forced his head against a structural support for an electrical panel. He was pronounced dead at the scene.
Key contributing factors identified in this investigation include:
- Inadequate equipment safeguard
- Inadequate lockout/tagout program and training
- Inadequate hazard assessment and knowledge of safeguarding equipment
- Inadequate training and assessing workplace hazards
Oregon Fatality Assessment and Control Evaluation (OR-FACE) investigators concluded that to help prevent similar occurrences, employers should:
- Safeguard machinery to protect machine operators and others who work in the area from hazards.
- Implement, enforce, and assess “control of hazardous energy (lockout/tagout)” procedures for machines, equipment and processes where unexpected energization or start-up could cause harm to personnel.
- Establish a safety committee that meets the requirements of Oregon Occupational Safety and Health Administration (OSHA).
- Confirm industry best practices for specialty equipment, and notify equipment manufacturers of equipment hazards identified in hazard assessments.