A traditional LOTO fatality – worker started equipment on another worker (TN-OSHA #23)

A 57-year-old supervisor was killed while trying to determine why hydraulic oil was leaking from a cotton press machine.  The press consists of a hydraulic pusher, tramper and bailer. The pusher and tramper sit on an elevated platform accessed by stairs; the bailers and operator console are located on the lower level. The cotton is blown into the pusher section by air through piping; the pusher pushes the cotton into the tramper section, the pusher retracts, and the tramper comes down to compact the cotton.  The tramper rises, and the process is repeated until a proper bale is formed.   The victim noticed a steady stream of oil coming from the platform under the pusher section of the press.  He told the press operator to shut the press down. He then went upstairs to the pusher section of the press where there was an access door on the right side which is interlocked with the pusher to shut it down when the door is opened.  When the access door was opened, the victim still could not determine the source of the leak.  He instructed a co-worker to remove the end and side panel of the pusher, but after looking inside, he could not see the leak.  He told a co-worker that the only way he would be able to figure out where the leak was located was to operate the pusher.  He told the co-worker to go downstairs to the control panel and tell the press operator to turn the press on and operate it.  The victim was standing at the side of the pusher when the co-worker left to go downstairs.   As instructed by the co-worker through hand signals, the press operator raised the tramper foot in manual mode and then stopped; there was no motion on the machine.  The co-worker then gave the usual verbal signal to the victim, yelling “here we go.”  He waited 5-10 seconds and heard no response from the victim.  Interpreting the lack of response to mean it was clear to proceed, he told the press operator to turn on the pusher.  The co-worker heard a yell.  He found the victim lying inside the pusher, with the portion of his body from the knees to his feet remaining outside the pusher.