OSHA Accident Investigation · Summary #14193916
WORK RULES,CONSTRUCTION,INEXPERIENCE,POINT OF OPERATION,UNGUARDED
Event description
Employee's finger cut in unguarded point of operation
Investigation abstract
A disc and roll machine, designed by its manufacturer to perform operations on s d, forming an inside flange. The mandrel head advanced two times per minute. Whe n set up for paper tubes, the machine was fed automatically by filling a feed bo wl and included an automatic shutoff in case of a misfeed or if the feed mandrel was left bare for any reason. A sliding perforated metal guard was used to bar access to the general point of operation. With the plastic sleeve setup neither the feed bowl nor the automatic shutoff feature could be used; instead, an incli ned feed chute had been installed that requires feeding by hand. This feed chute required removal of the guard. It was believed that the 12- to 15-in. distance between the feed point and the point of operation, and the interferences between these two points, coupled with the fact that access to the point of operation s mall sections of spiral wound paper tubing, had been in operation for over 10 ye hould not be needed without shutting down the system, made a guard unnecessary. Training was usually done either because the trainee had not worked with the mac hine at all or because it had been a while since it was last operated. It was cu stomary to pair an experienced operator with a trainee until both felt that the trainee was able to work alone. During Christmas week of 1984, the regular super visor was on vacation and his job was covered by a supervisor of related departm ents. They often covered for each other, since their departments were interrelat ed. Apparently, a machine operator without experience on the machine was assigne d to operate it. She cut one or more of her fingers and was hospitalized for her injury. ars. During this time the type of tubing used in the machine was changed from pa per to plastic. The machine consisted of a nine-mandrel head that rotated on a h orizontal axis with an adjustable-stroke horizontal push rod opposite each mandr el. About three to four months before the accident, the machine was set up to pr ocess plastic sleeves for D batteries. Precut sleeves were fed via the feed chut e into the machine, where a push rod shoved the tube partway onto a mandrel. It then rotated past a heater and one end of the tube shrinks around the mandrel en
Victim
-
#1 Hospitalized Age 61 F
- Nature of injury
- 7
- Part of body
- 10
- Event type
- 2
- Source
- 26
- Occupation code
- 717
- Human factor
- 9
- Environmental factor
- 4
- Task assigned
- 2
Codes shown verbatim from OSHA's accident-investigation database. A human-readable decoder is coming in a future release once the accident_lookup2 dictionary is loaded.