OSHA Accident Investigation · Summary #14252381
HEAD,BRICK SETTING MACH,WORK RULES,CLEANING,LOCKOUT,CAUGHT BETWEEN,SPREADER BAR,UNGUARDED,MACHINE--MISC
Event description
Employee killed when head caught in brick setting machine
Investigation abstract
At approximately 3:23 p.m. on March 22, 1990, Employee #1 was operating the sett found Employee #1's upper body lying on the table. Employee #1 died. The operat or yelled "man down" and the operator of the #2 brick machine ran and hit the em ergency stop button. The setting machine was being operated in the automatic mod e. Employee #1 had bypassed setting the machine to the manual mode and tried to fool the machine by hanging weights on the spring-loaded switches so that the ma chine components would do the opposite of what they were programmed to do. Immed iately after the accident, the panel was checked and a weight was found on the t able close switch. This allowed the table to remain open so that Employee #1 cou ld remove the clay caught in the spreader bars of the table. While Employee #1 w as performing this procedure, the head/carriage returned to home position; the s ing machine at the #3 brick machine in plant #6. He was cleaning out pieces of c ignal was already there for the head to come down and pick up a load of brick. W hen the table opens, the limit switch is signaled for the head to come down. The head came down, catching Employee #1's head between the fingers on the head and the spreader bars of the table. Causal factors include improper use of machine controls (not operating machine according to manufacturer's design) and lack of machine guards or guarding devices. lay from between the spreader bars. The brick machine operator noted that his co lumn slugs were being rejected at the setting machine. He checked at the setting machine and observed Employee #1 cleaning between the spreader bars on the tabl e. He also noted that the setting head/carriage was carrying brick to the kiln c ar. He returned to his position where he observed the head/carriage return to th e home position then immediately go down, and come up a few seconds later withou t a brick. He sensed that something was wrong. He ran to the setting machine and
Victim
-
#1 Fatality Age 27 M
- Nature of injury
- 12
- Part of body
- 13
- Event type
- 2
- Source
- 26
- Occupation code
- 779
- Human factor
- 4
- 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.