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Paper mill maintenance employee dies after being pinned by the arm of a control mechanism in a roll wrap machine.

Minnesota Department of Health
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 03MN039, 2004 Sep; :1-6
A 47-year-old male employee died after he was injured in a roll wrapper machine at a paper mill. The operator of the wrapper had contacted maintenance because the wrapper was not cycling. A mechanic who responded determined that there was not a mechanical problem so he called the Electrical & Instrumentation (E&I) Technicians. Three E&I Technicians responded and began to troubleshoot the wrapper. While troubleshooting the system, the wrapper was left in its operational mode, a normal procedure since it would be nearly impossible to determine the problem if the system were shut down. After troubleshooting the wrapper, it was suggested that it be cleared of all rolls of paper and the system be shut down and rebooted to reset it. While the E&I Technicians were troubleshooting the system, operations personnel were reviewing the lockout/tagout procedures for the wrapper. After the system was rebooted, one roll of paper was transferred to the first of two roll stop positions. The roll stop again failed to release the roll. Without notifying any of his co-workers, the victim went to the side of the wrapper opposite the computer control room. He crawled under the wrapper platform apparently to look for a switch called the ejector down switch. The switch senses the position of the wrapper's two roll stops and either allows or prevents rolls from moving across the wrapper platform. A diagram in the computer control room clearly indicated that the switch was located outside the wrapper frame. A steel plate that activates the ejector down switch is located beneath and near the center of the wrapper. The victim apparently proceeded to look in the area underneath and near the center of the wrapper. While he attempted to locate the switch, he was eventually guided by following the switch arm to the switch location on the outside of the wrapper frame. After locating the switch, he put his upper body through an opening in the side of the wrapper such that his torso was above the roll wrapper frame and directly below a raised control arm for one of the roll stoppers. A co-worker who happened to walk around the wrapper saw the victim at the moment he reached up and struck the switch with his fist. When the switch was struck, the wrapper immediately cycled. When the wrapper started, the roll of paper was released and it rolled forward to the raised bumper that was above the victim. The bumper descended as the roll came against it and crushed the victim between the wrapper frame and the bumper arm. A call was immediately made to emergency personnel who responded to the scene. The victim's co-workers immediately began to try to free the victim. He was eventually freed and removed however he had sustained traumatic crushing injures and was pronounced dead at the scene. MN FACE investigators concluded that, in order to reduce the likelihood of similar occurrences, the following guidelines should be followed: 1. employers should ensure that employees access restricted "areas" only by means of interlocking safety doors or gates. 2. Employers should ensure that employees shut down and lockout/tagout equipment before they enter any restricted hazardous areas. 3. Employers should securely install permanent barriers on all non-essential equipment "openings" that may pose a hazard risk to employees, and; 4. Employers should continuously stress the importance of strict adherence by all employees to established safe work procedures.
Region-5; 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-operators; Paper-mills; Paper-manufacturing-industry
Publication Date
Document Type
Field Studies; Fatality Assessment and Control Evaluation
Funding Type
Cooperative Agreement
Fiscal Year
Identifying No.
FACE-03MN039; Cooperative-Agreement-Number-U60-CCU-507283
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Minnesota Department of Health
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division