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Machine operator crushed between the plates of an injection mold while performing maintenance.
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 01CA007, 2001 Dec; :1-3
A 47-year-old machine operator died when crushed between the plates of a plastic injection mold. The victim was performing maintenance at the time of the incident. The victim was asked by the shift supervisor to correct one problem. A second problem arose when the victim activated the mold and the parts came out incomplete. The supervisor was the only person allowed to perform Lockout/Tagout on the machine but he wasn't asked and he didn't request that the victim let him do so prior to any further work on the machine. The victim did not disconnect any of the sources of energy. In an attempt to correct the second problem, the victim opened the sliding front gate guard, shielding the hydraulic plates, and stepped in between them. When the supervisor approached the machine, he saw where the victim was positioned and told the victim to get out of the machine, turned around and closed the sliding gate guard. The closing of this gate activated the machine and crushed the victim between the plates of the injection mold. The supervisor tried, but was unable to stop the machine in time to prevent this incident. The CA/FACE investigator determined that, in order to prevent future occurrences, employers, as part of their Injury and Illness Prevention Program (IIPP) should: 1. Ensure that all employees follow all manufactures and company safety procedures when operating and performing maintenance on machines. 2. Ensure employees are adequately trained and that workers' achievement of skills is verified through a testing program.
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; Machine-guarding; Machine-operation; Machine-operators; Maintenance-workers
Field Studies; Fatality Assessment and Control Evaluation
NTIS Accession No.
National Institute for Occupational Safety and Health
Public Health Institute
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division