NIOSHTIC-2 Publications Search

Operator of horizontal boring machine is crushed to death.

Iowa Department of Public 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 00IA003, 2001 Jan; :1-5
A 48 year-old machinist was crushed while lubricating a horizontal boring machine in an engine manufacturing facility. The horizontal boring machine is referred to as a block line machine that drills and bores holes horizontally in cast iron engine blocks. The horizontal boring process involves two employees that work together as a team. The first operator sets up the machine and inserts the engine block at the beginning of the line. The second operator walks the line at the other end of the machine, cleans and oils the bushings, removes engine blocks as they come off the end of the line, and gauges the bored hole. On the day of the incident, the first operator was called to assist on another machine-line. He told the second operator he was leaving, turned off the machine, and went to assist with the other machine. When he returned some time later, although he did not see the second operator, he turned the machine on to begin cycling more blocks. He looked around again for the second operator and when he did not see him, he walked to the backside of the machine and found the victim lying on the floor. The victim apparently had opened the safety gate to lubricate the machine and clean the bushing, and was crushed between the moving section of the boring machine and the machine frame when the first operator turned on the machine. Facility EMS personnel were notified and CPR started. Registered nurses, physician and EMS employees from the plant responded within minutes. A county deputy sheriff and ambulance personnel also arrived at the scene soon after being notified. The victim was transported to a local hospital where he was pronounced dead upon arrival. Recommendations based on our evaluation are as follows: 1. Employers should ensure that safety gates are locked-out or otherwise secured, while machines are in operation in order to prevent personnel from entering dangerous areas. A safety switch should be installed on the machine that disconnects the machine when the safety gate is open, and acts as a inter-lock gate. 2. Employers should ensure that employees follow safety procedures. A lock-out procedure must be followed during maintenance operations.
Region-7; 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; Equipment-design; Equipment-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-00IA003; Cooperative-Agreement-Number-U60-CCU-708674
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Iowa Department of Public Health
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division