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A machine operator died when caught in the threads being wound onto the take-up spool of a warping machine.

Public Health Institute
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 06CA006, 2007 Aug; :1-9
A 45-year-old machine operator died when he got caught in the threads being wound onto the unguarded spool of a warping machine. No one witnessed the incident, but it was recorded by a video surveillance camera. The victim became entangled while reaching toward the thread and take-up spool. The victim activated the emergency stop bar, but was completely wrapped in thread before the machine came to a stop. The company had no documented training program for their employees. The victim was the only employee at the company who knew how to operate the machine, and had only received a few hours of instruction in its use by the manufacturer's representative. The CA/FACE investigator determined that in order to prevent future occurrences, employers, as part of their Injury and Illness Prevention Program (IIPP), should: 1. Ensure employee safety by installing guards around the moving parts and pinch points of the machine to protect employees from accidental contact. 2. Ensure employees only use machines that are properly guarded and do not place any part of their bodies into areas where they might become entangled with machinery when it is running. 3. Ensure employees are properly trained on machine operation and safety and their achievement of skills is verified through a testing program. 4. Ensure employee safety by preparing and periodically updating a hazard analysis for all equipment. In addition: 5. Manufacturers should consider designing and installing an emergency brake system in conjunction with the emergency stop bar.
Region-9; Accident-analysis; Accident-prevention; Accidents; Injuries; Injury-prevention; Traumatic-injuries; Work-operations; Work-analysis; Work-areas; Work-performance; Work-practices; Safety-education; Safety-measures; Safety-monitoring; Protective-measures; Training; Equipment-operators; Equipment-design; Safety-equipment; Safety-practices; Safety-programs; Machine-guarding; Machine-operation; Warning-signs; Warning-devices; Machine-operation; Machine-operators; Work-operations; Work-practices; Equipment-operators; Emergency-equipment
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-06CA006; Cooperative-Agreement-Number-U60-OH-008468; Cooperative-Agreement-Number-U60-CCU-907284
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Public Health Institute
Page last reviewed: November 12, 2021
Content source: National Institute for Occupational Safety and Health Education and Information Division