Incident summary: An employee who was unwilling to wait for help recklessly tried to clear a machine jam without first locking out the equipment.
What happened: Shortly after the worker began operating a large packaging machine known as a unitizer, the stacker arms on the unit got stuck on top of poorly positioned boxes.
The crew member was working in an isolated area and didn’t know how to clear the jam, so he called his supervisor to request help. There was no response from his boss. He called another three times. After 45 minutes of waiting for a response, the operator decided to try to remove the jam by himself.
The staffer entered the machine’s perimeter gate without first locking out the dangerous device, and he began removing the boxes by hand. Without warning, his clothing got caught on moving parts and he was pulled into the unit.
About 30 minutes later, coworkers noticed that boxes were backing up on the equipment’s conveyor system, so they went to investigate. They found the operator unresponsive with his head and back crushed under the stacker’s arms against the conveyor.
Findings: Even though he’d been trained on his employer’s lockout/tagout protocols, the victim failed to deenergize the dangerous machine before he entered the perimeter gate, as he was required to do.
Furthermore, prior to the incident, a supervisor had permanently removed factory-installed safety guards that had provided a barrier protecting operators from the stacking arms. Had the guards been in place, it’s unlikely the victim would’ve been fatally pinned by the stacking arms.
(From the November 9, 2026, issue of Safety Alert for Supervisors. To start your no-obligation trial subscription to the publication right now, please click here).
