Incident summary: A staff member suffered fatal injuries to his neck after he bypassed a critical safety component on a hazardous machine.
What happened: Even though his employer had a safe work rule that forbade staff members from bypassing safety features on hazardous equipment, it had become routine for the operator of a hydraulic press to disregard the rule.
The press was equipped with an electric interlock switch that prevented it from operating while the front access door was open.
However, the equipment operator knew he could position a rag in the machine to bypass the interlock switch during equipment setup.
After circumventing the switch one day, the worker opened the access door to configure the machine for the next job. With the access door still open and the setup complete, the operator stepped back from the device and began to run the machine in jog mode. When the platen on the press descended, however, a metal balance pin inside the device fractured.
A piece of the pin was ejected from the machine. The debris struck the worker in the neck and severed several major blood vessels. The perforation injuries to the 52-year-old man’s thyroid and trachea were fatal.
Findings: The employer’s approach to machine guarding was flawed, said investigators. While the access door could’ve been an effective safety guard, it was too easy for people to bypass the interlock switch.
After the incident, the employer installed a fixed guard composed of thick gauge steel to more effectively shield workers from the point of operation and to better deflect flying debris.
(From the June 2, 2025, issue of Safety Alert for Supervisors. To start your no-obligation trial subscription to the publication right now, please click here.)