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Sheet operator dies after being crushed by the forks on a sheeting unit in California.

Public Health Institute
Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 95CA012, 1996 Feb; :1-4
A 26-year-old male sheet operator (the victim) died after being struck in the head with the loading arms (receiving forks) of a sheeter unit. This machine cuts and stacks cardboard in a folding carton operation, as part of the manufacture of cardboard boxes. The victim was adjusting the belts on the underside of the conveyor section of the unit when his co-worker, an apprentice, pushed the deadman switch to retract the receiving forks of the sheeter. He retracted the forks, according to standard operation procedures (SOP), to allow the cardboard resting on the forks to drop onto a pallet below. The unguarded forks move horizontally 39 inches forward and backward on the underside of the conveyor belt. As the forks retracted they struck the victim on the back left side of his head and knocked him to the floor. Although the apprentice and victim were in close proximity to each other (within 5 feet), the apprentice was unaware of the victim's location because the control panel of the machine was obstructing his view. The apprentice heard a loud noise and observed the victim lying on the floor underneath the sheeter. He immediately turned off the power to the sheeter unit and summoned help. Paramedics were called to the scene and upon arrival pronounced the victim dead. The CA/FACE investigator concluded that in order to prevent similar future occurrences, employers should: 1. guard all moveable parts of machinery with a wire screen or by other means to prevent employees from becoming exposed to moveable parts or other types of mechanical motion. 2. insure that adjustments of moving machinery can be made by employees in a safe manner. 3. have a standard operating procedure (SOP) specifying that all employees must be in clear view of the machine operator or that there is positive communication between all workers. In addition, product manufacturers and designers should: 4. assure that all components of machines, such as control panels, be installed in such a way that they do not obstruct operator view or otherwise put workers at risk. In addition, highly automated machines should be designed with no unguarded moving parts.
Region-9; 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; Safety-monitoring; Protective-measures; Equipment-operators; Protective-equipment; Equipment-design; Machine-guarding; Machine-operation; Machine-operators
Publication Date
Document Type
Field Studies; Fatality Assessment and Control Evaluation
Funding Type
Cooperative Agreement
Fiscal Year
NTIS Accession No.
NTIS Price
Identifying No.
FACE-95CA012; Cooperative-Agreement-Number-U60-CCU-907284
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Public Health Institute
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division