A 51-year-old female employee was fatally injured when she leaned into a machine and was pinned, resulting in crushing injuries to her head and neck. On the day of the incident, the victim was helping out on windshield #1 line due to low staffing levels resulting from inclement weather. She was to keep the line running and relieve other employees so they could go on break. The victim noticed the video inkjet on the #1 line was not printing correctly on the windshields. She notified the supervisor, who then left the area to stop the line so the inkjet could be repaired. When the supervisor returned to windshield #1 line, she found the victim with her head and neck pinned between the automatically actuated carriage carrying the windshield to the inkjet and a fixed metal portion of the machine. The investigation determined that the machine was not properly guarded to prevent physical entry into the machine while in operation, and the machine was not locked out before the victim entered the area, which allowed the machine to actuate.
Citation(s) as Originally Issued
A complete inspection was conducted at the accident scene. Some of the items cited may not directly relate to the fatality.
Citation 1 Item 1
29 CFR 1910.147(c)(4)(i) Procedures were not developed, documented and utilized for the control of potentially hazardous energy when employees are engaged in the activities covered by this section:
In that the employer did not ensure that lockout/tagout procedures were utilized at the windshield 1 line – star unload rotator cell when an employee was exposed to hazardous moving parts including, but not limited to, an automatically actuated carriage. An employee working at the machine was fatally injured after being crushed by the auto actuated carriage.
Citation 1 Item 2
29 CFR 1910.212(a)(1) One or more methods of machine guarding shall be provided to protect the operator and other employees in the machine area from hazards such as those created by point of operation, ingoing nip points, rotating parts, flying chips and sparks:
In that the employer did not provide adequate guarding to protect employees from leaning or reaching into the windshield 1 line – star unload rotator cell.
Photo 1 of 1 – Windshield #1 cell where the automatically actuated carriage crushed the victim. The red arrow indicates where the victim’s head was pinned between the mobile carriage and the fixed section of the machine.