Incident summary: A worker who hadn’t been retrained on new procedures for equipment operation was killed when a ram descended and ejected two aluminum safety blocks.
What happened: After noticing that the ram on a 200-ton press was slowly sliding down when it shouldn’t have been, supervisors asked the in-house machine shop to fabricate safety blocks that could be inserted in the operating zone of the press.
The in-house shop produced two aluminum blocks that measured 16.75 inches long by 3 inches wide by 3 inches deep.
Equipment operators were told to install the safety blocks whenever the press jammed. However, no training was provided on how to safely use the blocks.
Several weeks after the blocks had been fabricated, a worker was running the press and it was repeatedly jamming. He kept installing the blocks, clearing the jam and removing the blocks.
One time, however, he forgot to pull out the blocks. When the worker activated the press, the ram descended and the two aluminum blocks ejected from the unit.
One of the blocks struck the operator in the neck and chest. Coworkers raced to his assistance, but he was suffering heavy internal bleeding, and he was soon declared dead from his blunt force neck injuries.
Findings: Investigators determined that the blocks weren’t suitable for the machine. The company should’ve contacted the manufacturer before fabricating the blocks to confirm that they would work safely.
Plus, the press operator should’ve been provided with refresher training as soon as the procedures for operating the machine were changed.
(From the Dec. 6, 2021, issue of Safety Alert for Supervisors. To start your no-obligation trial subscription to the publication right now, please click here.)