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Worker killed when caught inside a palletizer hoist area - Massachusetts.

Massachusetts State 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 04MA006, 2007 Aug; :1-8
On March 16, 2004, a 45-year-old male machine operator (the victim) was fatally injured while operating and training a co-worker on a palletizing machine in an ice cream manufacturing facility. Palletizers place and stack product from the production line onto pallets to be shipped. Although un-witnessed, it appears that the victim entered the machine's hoist area to adjust the position of a pallet when the hoist began to rise with the victim on top of the pallet. A co-worker heard the victim yelling for help and ran to press one of the machine's emergency stop buttons. The victim was crushed between the empty pallet and the top portion of the hoist before the hoist stopped rising. The co-worker manually lowered the palletizer's hoist and the victim fell to the floor below. The co-worker in training was also an Emergency Medical Technician (EMT) and attended to the victim while Emergency Medical Services (EMS) were notified. When EMS arrived at the incident site, the victim was breathing on his own but was unconscious and unresponsive. EMS transported the victim to a local hospital where he was pronounced dead. The Massachusetts FACE Program concluded that to prevent similar occurrences in the future, employers should: 1. Minimize the number of times palletizers cycles are interrupted because of failures to detect pallets in the hoist area by routinely: (A) inspecting pallets for cracks and broken pieces, and, (B) evaluating the mechanism that transports pallets into the hoist area to ensure pallets are loaded into the hoist area properly; 2. Ensure that accessible moving parts of machines are guarded at all times to minimize access by employees; and 3. Develop, implement, and enforce a comprehensive hazardous energy control program including a lockout/tagout procedure and routinely review and update the program and training. In addition, palletizing system manufacturers should explore the feasibility of adding sensors to detect unplanned obstructions during the hoist's movement which would stop the hoist when obstructions are detected.
Region-1; 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; Training; Warning-devices; Machine-guarding; Machine-operation; Warning-systems
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-04MA006; Cooperative-Agreement-Number-U60-OH-008490; Cooperative-Agreement-Number-U60-CCU-108704
SIC Code
Source Name
National Institute for Occupational Safety and Health
Performing Organization
Massachusetts State Department of Public Health
Page last reviewed: May 11, 2023
Content source: National Institute for Occupational Safety and Health Education and Information Division