Rubber equipment operator died after his head was caught between bars of operating machinery, Oregon

SUMMARY

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.

CONTRIBUTING FACTORS
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

RECOMMENDATIONS
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.

Rubber equipment operator died after his head was caught between bars of operating machinery, Oregonpdf icon [PDF 1,408 KB]