A 48-year-old male employee was crushed inside a machine (COS) while adjusting the grippers that place lead cells into batteries. This employer is a battery manufacturer. On the day of the incident, the victim was called by the machine operator to troubleshoot the COS machine because the grippers were not working. It was determined that the operator would attempt to make the adjustments through manual mode alone. Still, if unsuccessful, maintenance will be called to enter the caged area to assist with the adjustment from inside the cage.
Employees are trained to put the COS machine in manual mode to prevent it from moving in normal production mode and leave the interlocking door open while in the caged area so the machine will not move or operate when they enter the caged area. However, interviews indicated that this procedure was only used when supplying or removing lead plates/posts and not for making adjustments to the grippers.
It was determined that to adjust the gripper fingers, a power supply was needed; therefore, LOTO was not used. When this additional step is required, the maintenance employees have to close the interlocked door to make the adjustments.
The victim called a contractor with WiTech to assist him in making the adjustments. (WiTech employees are contractors from Korea that worked in the employer’s Korean facility as maintenance employees on the same machinery.)
The victim entered the COS Machine through an interlocked door while the contractor and machine operator were outside the machine at the controls. The operator and the contractor manned the controls to make slight adjustments to the grippers, per the victim’s request from inside the cage. Additionally, they man the controls to ensure it stays in manual mode.