A 24-year-old man was crushed when caught between a retort machine and a stack of empty racks carried by a shuttle entering the machine. The victim entered the retort machine to clear dropped food cups from the inside of the machine without locking out the retort, which is typical activity at this location for this process. While inside the machine, the shuttle moved forward with empty racks. An emergency stop button had been engaged as the employee attempted climb out past the racks, however the program operating the shuttles appeared to require the machine to complete the last command and did not immediately stop, crushing the victim between the machine and the top of the racks. The machines were labeled “Confined Space – Enter by Permit only,” but there was no documentation that confined space entry or reclassification procedures had been followed.
Citation 1 Item 1
Type of Violation: Serious; $3,200
29 CFR 1910.146(c)(4): When the employer decided that its employees would enter permit spaces, the employer did not develop and implement a written permit space entry program that complied with 29CFR1910.146. In that a permit required confined space program to address the employees entering the retort machines at the facility, such as but not limited to the ALLPAX Rotary Water Spray Retort (Serial# 100720 AX3) was not implemented.
Citation 1 Item 2a
Type of Violation: Serious; $3,200
29 CFR 1910.146(c)(7)(i):If the permit space poses no actual or potential atmospheric hazards and if all hazards within the space are eliminated without entry into the space, the permit space may be reclassified as a non-permit confined space for as long as the non-atmospheric hazards remain eliminated. In that the Retort machines at the facility were reclassified as non-permit confined spaces when all hazards were not eliminated.
Citation 1 Item 2b
Type of Violation: Serious
29 CFR 1910.146(c)(7)(iii): The employer did not document the basis for determining that all hazards in a permit space had been eliminated, through a certification that contained the date, location of the space, and/or signature of the person who made the determination, and/or the certification was not made available as required.
In that the retort machines had been reclassified to non-permit required confined spaces by the employer and there was no documentation showing the basis of determining that all hazards had been eliminated for reclassification of the retort machines from a Permit Required Confined Space to a Non-permit Required Confined Space.
Proposed Penalty: Grouped with 1 / 2a
Citation 1 Item 3
Type of Violation: Serious; $2,800
29 CFR 1910.146(g)(1): The employer did not provide training so that all employees whose work was regulated by 29 CFR 1910.146 (permit required confined spaces) acquired the understanding, knowledge, and skills necessary for the safe performance of the duties assigned under 29 CFR 1910.146.
In that employees had not been trained with the skills necessary for safe performance of duties while working in a permit required confined space at the facility, such as the ALLPAX Rotary Water Spray Retort machine (Serial# 100720 AX3).
Citation 1 Item 4
Type of Violation: Serious; $4,500
29 CFR 1910.147(c)(4)(i):Procedures were not developed, documented and utilized for the control of hazardous energy when employees were engaged in activities such as servicing and/ or maintenance of equipment. In that when entering the ALLPAX Rotary Water Spray retort machines to remove soup cups, lockout is not utilized, allowing the shuttle to continue to try and place racks inside the retort machines. On 08/29/2024 an employee was fatally injured when he entered the ALLPAX Rotary Water Spray Retort machine (Serial# 100720 AX3) to remove fallen soup cups and the shuttle continued to place racks in the retort machine pinning the employee between the racks and the retort machine.
Citation 1 Item 5
Type of Violation: Serious; $3,200
29 CFR 1910.147(c)(4)(ii): The energy control procedures did not clearly and specifically outline the scope, purpose, authorization, rules, and techniques to be utilized for the control of hazardous energy, including, but not limited to items (a) through (d) of this section:
In that the machine specific lockout procedure for the ALLPAX Rotary Water Spray Retort machines did not include steps to isolate the hazard associated with the following:
a. steam and water
b. movement of shuttle to place racks into the retort machine(s)
c. continued movement of the shuttle after placed into “Out of Service” mode in the HMI (shuttle computer)
Citation 1 Item 6
Type of Violation: Serious; $4,500
29 CFR 1910.147(c)(6)(i): The employer did not conduct a periodic inspection of the energy control procedure at least annually to ensure that the procedure and the requirement of this standard were being followed:
In that a periodic review of the lockout procedures for the ALLPAX Rotary Water Spray Retort machine (Serial# 100720 AX3) had not been completed for the employee fatally injured at the facility on 08/29/2024.
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