OSHA Accident Investigation · Summary #14382113

BURN,DIE,SPLEEN,LOSS OF BLOOD,WORK RULES,LOCKOUT,CRUSHED,ARM

1986-12-30T00:00:00

Event: BURN,DIE,SPLEEN,LOSS OF BLOOD,WORK RULES,LOCKOUT,CRUSHED,ARM
Linked inspection: No inspection record linked to this accident's victims.
Summary number: 14382113
Report ID: 521400

Event description

EMPLOYEE CRUSHED BETWEEN DIES OF ALUMINUM CASTING MACHINE

Investigation abstract

EMPLOYEE #1, A DIE REPAIR TRAINEE FOR APPROXIMATELY SEVEN MONTHS, WAS RESPONSIBL ETWEEN THE DIES, FROM THE OPERATOR'S SIDE, TO BEGIN POLISHING. AS EMPLOYEE #1 WA S MOVING IN BETWEEN THE DIES, THE MACHINE OPERATOR STATED THAT HE NOTICED THE AU TOMATIC LADLE ON THE MACHINE WAS ABOUT TO POUR A "SHOT" OF MOLTEN METAL INTO THE PLUNGER. THE MACHINE OPERATOR STATED THAT HE TOLD EMPLOYEE #1 TO "HOLD ON FOR A MINUTE", BUT APPARENTLY EMPLOYEE #1 DIDN'T HEAR HIM OR JUST IGNORED HIM, AND CO NTINUED TO CLIMB INTO THE MACHINE BETWEEN THE DIES. THE MACHINE OPERATOR THEN ST ARTED THE MACHINE IN AN ATTEMPT TO MANUALLY DUMP THE MOLTEN ALUMINUM THE AUTOMAT IC LADLE BEFORE IT FROZE. AS THE OPERATOR WAS ATTEMPTING THE DUMP, THE MACHINE P ARTIALLY CYCLED. EMPLOYEE #1 WAS CAUGHT AND CRUSHED BETWEEN THE DIES. HE EXPERIE NCED SEVERE BURNS TO THE ARMS AND HIS DIAPHRAM, SPLEEN AND LIVER WERE CRUSHED WI E FOR THE MAINTENANCE OF DIE CASTING MACHINE DIES AND TRIM TOOLING UNDER THE DIR TH SEVERE INTERNAL BLEEDING. THE MACHINE WAS NOT LOCKED OUT AT THE MAIN POWER DI SCONNECT, NOR WAS A SAFETY BAR INSTALLED BETWEEN THE DIES WHILE EMPLOYEE #1 WAS WORKING THERE. LOCK OUT OF THE DIE CASTING MACHINES WAS NOT STANDARD PRACTICE AT THE PLANT FOR POLISHING OPERATIONS, BUT SAFETY BARS ARE SUPPOSED TO BE USED. ECTION OF THE TOOL ROOM MANAGER. EMPLOYEE #1 APPROACHED THE EX-CELLO CORPORATION B & T COLD CHAMBER DIE CASTING MACHINE #5 (MODEL 700CC) WITH INSTRUCTIONS TO PO LISH THE UPPER CORNER OF THE DIE ON THE HELPER'S SIDE, DUE TO A PORT QUALITY CON TROL PROBLEM. THE PROBLEM WAS DISCOVERED BY THE COMPANY'S INSPECTOR AND RELAYED TO EMPLOYEE #1 THROUGH THE TOOL ROOM MANAGER. THE MACHINE OPERATOR OF B & T #5 S TATED THAT EMPLOYEE #1 TOLD HIM TO SHUT DOWN THE MACHINE. HE DID SO BY PRESSING THE MOTOR STOP BUTTON ON THE CONTROL PANEL. EMPLOYEE #1 THEN PROCEEDED TO STEP B

Victim

#1 Fatality Age 30 M

Nature of injury
21

Part of body
19

Event type
2

Source
26

Occupation code
999

Human factor
13

Environmental factor
4

Hazardous substance
8880

Task assigned
1

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