Machine operator fatally struck by safety block ejected from mechanical power press , New York
New York Case Report: 16NY064
On December 6, 2016, a 49-year-old male worker at a busbar manufacturing facility was fatally injured while operating a 200-ton press around 11:20 AM. The decedent and another employee were in the process of making busbars, a component of electrical devices, out of raw copper strips using a 200-ton mechanical press. The press frequently jammed, requiring the decedent to place two safety blocks between the ram and bolster and reach into the press to unjam the machine. The decedent would then remove the safety blocks and return to actuate the machine at a dual-button control panel mounted to a pedestal, placed in front of the long side of the press. The decedent and the shift supervisor had to unjam the press multiple times. The last time they removed the jam, the safety blocks were unintentionally left on the bolster bed. The decedent, who was standing in front of the press by the pedestal controller, actuated the press. The two safety blocks were immediately ejected from the press; one block struck the decedent in the neck and chest inflicting severe injuries. Immediately after the injury, 911 was called, and another employee tried to help with basic first aid. Emergency medical technicians (EMTs) responded in minutes, but the employee died at the scene due to blunt force injuries to the neck.
Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events. The NY FACE investigation identified the following key contributing factors in this incident:
- Safety blocks were left in the press when the press was actuated.
- Safety blocks were not interlocked to the press circuitry.
- Safety blocks were not aligned with the longitudinal central axis of the ram, causing a pressure difference between the two halves of the press.
- The operator was in the path of the projectile.
- No written procedures for setting up the machine, placing dies, clearing jams from the machine, or locking out the machine existed for reference by the operator(s).
- Limited training on the press was given to the decedent prior to his utilization of the press.
NY FACE investigators concluded that, to help prevent similar occurrences:
- Employers should ensure that interlock devices are used in conjunction with safety blocks when working with mechanical power presses.
- Employers should ensure that the selected safety blocks meet the rated capacity of the specific power presses.
- Employers should place safety blocks centered along middle length of press when servicing.
- Employers should ensure that press controls are moved to short ends of press to avoid risk of being struck by materials ejected during press operation.
- Employers should design machine guarding that allows for the safe movement of all employees around active machinery.
- Employers should deploy a maintenance and inspection schedule of mechanical presses.
- Employers should ensure employees are thoroughly trained on machines they operate.
- Employers should conduct Job Hazard Analyses (JHAs) for specific tasks and instruct employees on how to safely work with and troubleshoot machinery issues during normal production operations.
- Employers should train employees in Lock-out Tag-out (LOTO) procedures.
Machine operator fatally struck by safety block ejected from mechanical power press [PDF 643 KB]