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Machine operator dies after being struck by a shredder grate during shredding machine maintenance.

Michigan State University
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 06MI009, 2007 Jun; :1-15
On February 16, 2006, a 42-year-old male machine operator was critically injured after being struck by a 2,500-pound iron grate that he was removing from a metal shredding machine (also known as a hammer mill). There were 13 grates that required removal. Each grate lay in a track, which held them in position in the shredder box. Five grates had been removed. To remove a grate, the decedent attached a separate steel alloy chain to each end of the grate and a mobile crane lifted the grate out of the machine via the grate track. The incident occurred during the removal of the sixth grate. The grate was located at a five o'clock position. The decedent had attached the chains to the grate and the hoisting process began. The grate became stuck in the grate track. To facilitate its removal, the decedent used a torch to partially cut through the grate while it was still under tension from the crane. The crane again attempted to lift the grate from the machine. Because the grate again did not move, the decedent cut through the grate end while the grate was still under tension. When the grate was cut through, the momentum of coming to center caused the grate to continue past center and strike the decedent in the side of his head. 911 was called and the decedent was transported to a local hospital where he died three days after the incident. Recommendations: 1. Employers should conduct a job safety analysis (JSA) when performing non-routine tasks or using non-routine tools, develop a standard operating procedure for the identified tasks, and train applicable employees on the procedure. 2. Employers should provide rigging training to employees involved in lifting a heavy load with load-bearing equipment. 3. Employers should form a joint Health and Safety committee. Although not a factor in this incident, MIFACE recommends: 4. Employers evaluate the workplace to identify any confined spaces and develop and enforce written work procedures for entry into these areas. 5. Employers establish written lockout/tagout procedures to provide employee protection from injury due to unexpected/unintended motion, energization, start-up or release of stored energy from the machine, equipment or process when working in, on, or around the equipment during repair, maintenance or other associated activity.
Region-5; Accident-analysis; Accident-potential; Accident-prevention; Accidents; Injuries; Injury-prevention; Safety-education; Safety-practices; Safety-measures; Traumatic-injuries; Work-practices; Work-analysis; Work-performance; Equipment-operators; Safety-education; Safety-monitoring; Safety-programs; Training; Workplace-monitoring; Work-operations; Work-environment; Work-areas; Machine-operation; Machine-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-06MI009; Cooperative-Agreement-Number-U60-OH-008466; Cooperative-Agreement-Number-U60-CCU-521205
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Michigan State University
Page last reviewed: December 17, 2021
Content source: National Institute for Occupational Safety and Health Education and Information Division