OSHA Accident Investigation · Summary #14565832
HEAD,POWER PRESS,WORK RULES,LOCKOUT,CAUGHT BETWEEN,POINT OF OPERATION,MECH MALFUNCTION,UNGUARDED
Event description
Employee killed when caught in power press
Investigation abstract
At approximately 7:00 a.m. on June 21, 1986, Employee #1, the lead die set-up pe s crown. She was transported to University Hospital, where she died at 9:15 a.m. of severe head injuries. The inch control button was not guarded against accide ntal contact. The die setter had twice told Employee #1 to get off the press and let maintenance take care of it. Employee #1 violated company safety policy by climbing on the press bed while the drive motor was running. rson, told the die setter to change the die in the Verson mechanical power press , model #150-52-22. The press was put in the inch mode and the ram was brought t o dead bottom. The die setter could not raise the press ram using the rise contr ol, which would bring it up slowly, so he told Employee #1 to call maintenance. Instead, she climbed onto the press bed, leaned over the top of the ram, and tap ped on a micro switch with a bolt. As she started to get down off the press, her right arm or hand contacted with the inch control button, actuating the press a nd cycling the ram. Her head was pinched between the top of the ram and the pres
Victim
-
#1 Fatality Age 33 F
- Nature of injury
- 12
- Part of body
- 13
- Event type
- 2
- Source
- 26
- Occupation code
- 999
- Human factor
- 1
- Environmental factor
- 1
- 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.