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Machinist is pinned between parts of metal materials handling equipment.

Wisconsin Department of Health & Family Services
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 95WI055, 1996 Jan; :1-5
A 52-year-old male machinist (the victim) died as a result of crushing injuries he sustained after being pinned between a turnstile arm and a metal beam on a conveyor line. He had been working at the metal fabricating company where the incident occurred for six days prior to the incident. Prior to being hired at the new company, he had worked for twenty years at another company where he operated a manually operated tilt-table (downender). During his employment with the new company, he worked in the shipping department and had not been trained to operate the company's automatic downender. About ten minutes before the incident, the production control manager (the supervisor) asked him to help with the process of transferring rolls (coils) of metal alloy from a turnstile to the downender. This segment of the conveyor line was automatically controlled by buttons on a control panel, in front of the downender. On the afternoon of the incident, the supervisor was operating the control panel while the victim worked under his direction. During the first part of the cycle, the turnstile arm holding the coils turned 90 degrees to align with a projecting beam from the center of the vertical downender. Usually, an automatic pusher transferred the coil from the turnstile to the beam. If the transfer was incomplete, a worker would manually push the coil onto the beam. The second part of the cycle consisted of the downender tipping to the horizontal position, then retracting the beam, and automatically moving the coil to the conveyor table. There were no warning lines around the turnstile or machine areas, nor were guards in place at the pinch point between the beam and the turnstile arm or pressure pads on the floor. Just prior to the incident, the first coil on the turnstile failed to completely transfer to the beam, so the victim was directed to push it off the arm and onto the beam. After the coil was transferred, the downender had tipped to the horizontal position and the victim was standing near the turnstile arm, when the supervisor left the control panel to remove materials from the conveyor. The victim apparently went to the control panel and pushed a button to resume the cycle, then returned to the turnstile area. A few moments later, the supervisor heard the victim call for help, and turned to see him pinned between the turnstile and the downender beam. The supervisor went to the control panel and tried to retract the beam, but was unsuccessful. He then pushed the emergency stop button, and cut the hydraulic line to retract the beam. The victim was transported to the hospital by EMS services, where he was pronounced dead. The FACE investigator concluded that, to prevent similar occurrences, employers should: 1. Ensure that access to hazardous areas is sufficiently guarded. 2. Develop, implement and enforce a written safety program which includes, but is not limited to, worker training in hazard identification, avoidance and abatement. 3. Ensure that all workers receive instructions on safe work practices in a manner that is clear, complete, and understandable to the employee. 4. Encourage workers to actively participate in workplace safety.
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; Safety-programs; Training; Machine-operation; Machine-operators; Machine-shop-workers; Machinists; Machine-guarding
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-95WI055; Cooperative-Agreement-Number-U60-CCU-507081
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Wisconsin Department of Health & Family Services
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division