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Operator crushed while repairing running machine.

Oregon Department of Human 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 05OR005, 2006 Mar; :1-6
On March 17, 2005, a 61-year-old woodworker operating a glue-press machine at a wood-products firm was killed while attempting to replace a glue tray while the machine was running. The glue tray had been removed to correct a glue-dripping problem. The press operator instructed another worker to finish processing a product that was already in the press, while he and a new coworker attempted to reattach the glue tray. The press operator put his head between the frame and the closed top lid of the press in order to see where to latch the glue tray. While he was in this position, the top plate suddenly lifted at the end of a programmed automatic cycle, and crushed the operator's head against the frame. Coworkers witnessed the event and immediately extricated the operator from the machine. The victim was transported to the hospital, where he was pronounced dead. Recommendations: 1. Completely shut down and lockout machinery before conducting maintenance. 2. Employers should develop, implement, and enforce a comprehensive hazardous energy program. 3. Ensure that all machinery moving parts and pinch points are fully guarded. 4. Employers should conduct regular hazard surveys and follow through with corrective action. 5. Employers should investigate on-the-job injuries and review work procedures in order to correct hazards and prevent similar incidents. 6. Employers should implement a preventive maintenance program for machinery, with designated, trained personnel authorized to perform maintenance tasks.
Region-10; Accident-analysis; Accident-potential; Accident-prevention; Accidents; Construction-equipment; Construction-workers; Injuries; Injury-prevention; Traumatic-injuries; Equipment-operators; Training
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-05OR005; Cooperative-Agreement-Number-U60-CCU-021204; Cooperative-Agreement-Number-U60-OH-008324
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Oregon Department of Human Services
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division