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Maintenance Mechanic Crushed Working Inside of a Vertical Storage Machine, Oregon

Oregon Case Report: 17OR022
Release Date: June 2019


On July 12, 2017, a 49-year-old Certified Field Technician was killed after he climbed into a mechanical vertical storage unit to facilitate repairs. He had a new, inexperienced employee with him on the day of the incident; the Technician was training the new employee (Trainee) to perform routine preventive and/or scheduled maintenance (PM and/or SM). They completed one PM in the morning on a vertical storage machine. Work on a second machine was started after lunch at approximately 12:45 pm. A roller used to support a carrier tray fell out, and the Technician could not reinstall it from outside the machine. A carrier was removed to provide space for him to enter the unit. He climbed inside, to lie on a carrier below the removed one. As the trainee cycled the machine to put the Technician in a position to access and reinstall the roller, the machine malfunctioned. The Technician asked the trainee to make another input to the controls. The machine advanced the Technician over the top of the vertical storage unit, which had very limited space. This action crushed the Technician, leaving him on the sealed side, opposite the side where he started. Pry bars were used to extricate the Technician but resuscitation attempts failed.

Key contributing factors identified in this investigation include:

  • Work being performed inside of an energized machine that was not treated as a confined space
  • Lockout/tagout (LOTO) procedures were not applied
  • Inadequate access to/knowledge of, alternate, safer method(s) to perform the work (i.e. options to work
    from outside the machine or rotate carriers without power)
  • Failure to stop work despite an apparent machine malfunction.
  • Inadequate training and communication regarding specific job hazards

Oregon Fatality Assessment and Control Evaluation (OR-FACE) investigators concluded that to help prevent similar occurrences, employers should:

  • When selecting and installing equipment, ensure that maintenance can be performed without exposing
    employees to hazards. Making safe access easier and quicker will encourage safer work practices.
  • Follow lockout/tagout procedures to reduce the risk of hazardous movement of machines prior to work in
    a confined space, and seek advice or consult the machine manual if unsure how a task can be
    accomplished in a de-energized machine (e.g., hand crank).
  • Employers should never allow entry into a confined space that contains physical hazards until there is a
    positive movement control method developed.
  • Routinely assess job hazards, provide regular, periodic training and communications on site-specific
    hazards and safe work practices, and take corrective action when needed. Check and monitor employees’
    knowledge of job hazards and implementation of safe practices to control hazards.
  • Ensure the equipment manual is available and reviewed prior to working with equipment.
  • Provide appropriate audits of lockout/tagout use (annually at a minimum).
  • Equipment/Facility owners should ensure safe work practices are followed, and inform contractors and
    their employers when discrepancies are observed.

Maintenance Mechanic Crushed Working Inside of a Vertical Storage Machine, Oregon [PDF 1,686 KB]