NIOSH Case Studies

Case Report: 02NY096

On December 21, 2002, a 54 year-old Taiwanese male food production worker, who was employed by a pizza dough manufacturing facility, sustained fatal injuries as a result of deep neck lacerations made by a steel blade on a dough machine. On the day of the incident, the victim and a co-worker were assigned to clean two dough machines, an “elevator” and a “divider”. The “elevator” had three major components: a lifting mechanism, a hopper, and a steel blade (“dough chunker”) that was located at the bottom of the hopper. The facility’s Lockout/Tagout procedure required an operator to set the control buttons of the “dough chunker” to “Off” and “Manu” before turning off the main power switches. Prior to the incident, the victim turned off and locked the power switches, but left the “dough chunker” controls set to “On” and “Auto”. The victim and the co-worker then proceeded to clean the machines. At approximately 4:15 PM, the co-worker was ready to clean the dough bowl on the “elevator”. In order to clean the outside of the bowl, he had to have the bowl raised by the “elevator”. He went to the victim and asked him for the key to unlock the main power switch to the “elevator”. At this point the victim was in the middle of cleaning the inside of the “elevator” hopper. He was standing on a metal stair, bending over and extending his head through the bottom opening of the hopper and wiping the inside of the hopper with a rag. When asked, the victim gave his key to the co-worker. The co-worker walked to the control panel, unlocked the main power switch, turned it on, and started raising the bowl. A few seconds later, the co-worker heard noises made by the victim. He immediately pushed the emergency stop button to stop the machine. The co-worker rushed to the victim and saw that the victim appeared to be partially decapitated from behind by the Energized steel blade. The co-worker called the shift supervisor for help. The shift supervisor summoned the paramedics who arrived within five minutes. The victim was pronounced dead at the scene and was transported from the accident site to a local hospital morgue.

New York State Fatality Assessment and Control Evaluation (NY FACE) investigators concluded that to prevent similar incidents from occurring in the future, employers should:
  •  Conduct periodic inspections to ensure that company lockout/tagout procedures are being strictly followed;
  •  Update the company’s lockout/tagout program to include specific shutting down procedures for the “elevator”;
  •  Modify the cleaning procedure to avoid placing the workers’ body into the point of operation;
  •  Install interlocks to eliminate possible human errors during machine maintenance and sanitation;
  •  Provide immediate employee retraining to ensure that the workers understand the key elements of the lockout/tagout program.

FACE Report: 9717

On April 18, 1997, a 37-year-old male Maintenance electrician (the victim) died when his lower torso was crushed between the nip barrier (a wire-mesh gate) and the upper frame of a paper rewinder machine at a paper-manufacturing facility. Without first de-energizing, locking out, and tagging the machine, the victim began to replace the arm for the limit switch that controlled upward movement of the nip barrier. He climbed an 8-foot stepladder to access the top of the machine where the switch was located, and leaned into the 16-inch opening between the top of the nip barrier and the upper frame of the machine. Co-workers observed him reaching with a screwdriver into the area where the switch was located. Apparently, he inadvertently activated the limit switch and the nip barrier raised, carrying the victim and the stepladder upward and compressing both between the nip barrier and the upper frame of the machine. The victim's waist to lower back area was crushed. A co-worker paged the plant safety watchman, who contacted the rescue squad. The rescue squad arrived within 2 minutes, and the victim was pronounced dead at the scene. NIOSH investigators concluded that, in order to prevent similar incidents, employers should:
  •  Ensure that maintenance workers follow established lockout/tagout procedures for control of hazardous energy
  •  Conduct regular worksite evaluations to ensure adherence to established procedures for control of hazardous energy
  •  Train production workers and other non-maintenance workers to recognize potential workplace hazards and participate actively in workplace safety.

FACE Report 2006-02

On January 17, 2006, a 52-year-old millwright (the victim) was fatally injured when he was pinned between the feed rolls of a debarker as he was welding additional metal to the teeth on the feed rolls. The victim had locked out two electrical disconnects in the debarking room before beginning his work, but he had not locked out all electrical disconnects and had not shut off and locked out the airline to the machine. As the victim welded, he leaned forward and placed his head between the upper and lower feed rolls to reach areas that required more metal. The air pressure on the rolls automatically cycled and the feed rolls closed over the victim’s head.

The victim had been working alone. His supervisor had left the area to check on another machine. When the supervisor returned to the area about 20 to 30 minutes after he had last seen the victim, he found that the victim had been caught in the machine. The supervisor called on the company radio for help and for someone to call 911. He then turned off the air line. When he returned, he and other employees used a chain jack, commonly referred to as a “come-along,” to lift the upper feed roll off of the victim. They removed him from the machine and placed him on the floor next to the machine. Emergency medical services (EMS) personnel arrived approximately 20 minutes after receiving the 911 call and attempted to do cardiopulmonary resuscitation but to no effect. They called the coroner who came to the site and pronounced the victim dead.

NIOSH investigators concluded that, to help prevent similar occurrences, employers should:
  •  Ensure that hazardous energy control safety procedures clearly identify all potential sources of energy for each machine and that the location and the method for control is clearly identified. Workers should be routinely trained on the procedures.
  •  Ensure that all hazardous energy, including pneumatic energy, is locked out, and any stored energy is released before repair work begins.
  •  Follow the equipment manufacturers’ recommendations for removal, maintenance, repair, and/or replacement of machine parts.
  •  Ensure that employees are adequately trained and supervised when assigned to perform new, infrequent, or dangerous tasks.
  •  Contact the equipment manufacturer for assistance in redesigning machine systems to reduce the number of lockouts needed to render the equipment safe for repair and maintenance.

Investigation # 98TX07101

A 52-year-old, male computer support technician (the victim), at a communications company died after being crushed in a stationary trash compactor. The victim had gone to the company loading dock to look for a computer shipping box which had been mistakenly thrown into the trash compactor. He turned on the compactor using the key located in the switch. The compactor started its normal cycle and the ram inside the charging chamber raised to the up position. While the ram was at the top of its stroke, he leaned over the compactor's loading sill to look inside the machine. The ram moved down to complete its cycle, struck him on the back and crushed him against the loading sill. A co-worker who was nearby heard the victim groan, went to the compactor and found him. With the assistance of another co-worker, the victim was lifted out of the compactor while another co-worker called 911. The incident occurred at 10:00 a.m. EMS personnel arrived within minutes and found the victim was dead from his injuries.

The TX FACE Investigator concluded that to reduce the likelihood of similar occurrences, employers should:
  •  Ensure that workers are protected from the unexpected movement of machine parts by developing lockout/tagout procedures as required by OSHA regulation 29 CFR 1910.147 - Control of Hazardous Energy (lockout/tagout)
  •  Establish an operating policy for trash compactors that includes training in safe operating procedures, identification of authorized operators, and measures to prevent unauthorized operation.

Additionally, employers and owners of trash compactors should:
  •  Ensure that the machines are properly equipped, inspected regularly, and maintained according to ANSI Z245.2 - Stationary Compactors Safety Requirements.

Investigation: # 03CA006

A 48-year-old Hispanic male machine operator died when he was crushed inside a plastic injection molding machine. Evidence suggests the victim was attempting to adjust or repair the machine or one of its components when the incident occurred. Company policy was for machine operators to contact a shift supervisor whenever repair was needed on a machine. The company's Lockout/Tagout procedure was not used when this incident occurred. The CA/FACE investigator determined that, in order to prevent future occurrences, employers, as part of their Injury and Illness Prevention Program (IIPP) should:
  •  Ensure employees stay within their assigned scope of work.
  •  Ensure machine operators follow company policy and implement the lockout/tagout procedure when applicable.

FACE Report: 96NE035

A 44-year-old Maintenance mechanic died as a result of injuries sustained when he was crushed in an angle iron processing machine. He had been performing maintenance on the machine and was tightening some bolts when the incident occurred. He was lying on a concrete floor between the main body of the machine and a moving carriage while tightening the bolts. The moving carriage crushed him between the main body of the machine and the carriage. The machine was not locked/tagged out prior to the task being performed at the time of the incident.

The Nebraska Department of Labour investigator concluded that to prevent future similar occurrences:
  •  Employers and employees must ensure that lockout/tagout procedures are followed at all times.
  •  Employers must ensure all machines have adequate machine guards installed.
  •  Employers should consider installing sensors (light, pressure, motion or floor) on automated machinery with the potential for causing serious injury or death.
  •  Employers should consider implementing a spot inspection program to ensure all employees are complying with safety requirements and enforce consequences for noncompliance.

FACE Report: 9514

On August 29, 1995, a 22-year-old male machine operator (the victim) died from injuries he received after being struck by the elevator of a concrete block cuber machine. The cuber machine was part of the plant's concrete block manufacturing equipment. The machine was connected to a conveyor belt system that directed concrete blocks onto the cuber's elevator which then raised and arranged the blocks into cubes of 90 blocks each. The cubes were transferred via conveyor belt to the strapping area. The event was unwitnessed; however, it is assumed that a cube of concrete blocks became lodged on the conveyor belt near the cuber's elevator. The victim, without first shutting off and locking/tagging out the machine, opened a manually operated access gate into the machine's operating area. The victim positioned himself partially under the raised elevator and used a piece of wood to try to dislodge the cube of blocks. At that time, the cuber machine cycled and its elevator dropped, striking the victim on the lower spine. About 1 minute later the president of the company was walking by the area and noticed the victim trapped beneath the elevator. The president shut off the machine and had another worker call the emergency medical service (EMS). The EMS arrived at the site in 6 minutes. EMS personnel performed defibrillation and cardiopulmonary resuscitation, and transported the victim to a local hospital where he was pronounced dead on arrival. NIOSH investigators concluded that, in order to prevent similar incidents, employers should:
  •  Develop, implement, and enforce a written safety program which includes task-specific training and lockout/tagout procedures
  •  Consider the development and installation of interlocking gates that protect workers from exposure to hazardous energy
  •  Conduct a safety hazard analysis of all work locations in all plants, and implement corrective action where necessary.

FACE Report: 2001-08

A 36-year-old male paper factory worker (the victim) died from crushing injuries after being caught by the ram inside a 2-stage horizontal baling machine. The victim, working alone in the warehouse area of a paper plant, was compacting waste paper when at some point in the compacting process he entered (either intentionally or advertently) the compression chamber and was caught by the machine's hydraulic ram. The victim was discovered by a co-worker, who notified the plant manager to call police and emergency medical services (EMS).

Both a fire department rescue squad and EMS arrived at the site. They extracted the victim from the baler. The victim was pronounced dead at the site by the medical examiner.

Subsequent examination by investigators revealed that the baling machine was not shut off and locked out and that the safety interlock on the compression chamber door may have malfunctioned, allowing the machine to operate with the door in the open position.

NIOSH investigators concluded that, to help prevent similar incidents, employers should:
  •  Ensure that workers are protected from the unexpected movement of machine parts by implementing lockout/tagout procedures (OSHA regulation 29 CFR 1910.147 - Control of Hazardous Energy [lockout/tagout])
  •  Ensure that all safety devices are functioning correctly
  •  Establish written operating procedures for machinery that include training in safe operating practices and a safe method for clearing jams

Case Report: 03KY115

On July 4, 2003, a 36-year-old male lead electrician died after being electrocuted with 480 volts of electricity. A crew of five licensed electricians were working at an automotive supply manufacturing facility running wires to connect service for two air conditioning units (3-phase; 480 volts; 30 amp and 35 amp) and service for a lighting panel (3-phase; 277/480 volts and 200 amps). The manufacturing facility had been shut down for the holiday, and besides a facilities office worker in the facility’s main office, the five men were the only workers at the site and had complete control of the facility utilities (they were the only ones who had the ability to turn on/off utilities at the facility). Normally, everyone who was working directly with wiring or who could come in contact with live electric wires would place their lock and tag on the appropriate breaker or other control device to guard against unexpected energy being released. This time, it was decided by the crew only the job foreman would use his Lockout/Tagout equipment on the breakers.

The victim was sitting in a 4’x 4’ junction box with another employee pulling wires to connect two air conditioning units and service to a lighting panel. Having completed the wiring connection for the lighting service, the lead electrician instructed the job foreman to throw on the breaker to the lighting service while he continued to run the wiring for the two air conditioning units. Instead, the foreman thought he was supposed to throw on the breakers for both the lighting service and the air conditioning services, which he did. As the foreman threw on the breakers, the lead electrician was holding the wiring for the air conditioning service in his hand and was electrocuted. Upon the lead electrician collapsing, the foreman summoned emergency services to the facility while another co-worker administered CPR to the victim. Paramedics arrived and transported the decedent to a nearby hospital where he was pronounced dead. To prevent future occurrences of similar incidents, the following recommendations have been made:
  •  Employees should always follow company lockout/tagout procedures.
  •  Communication between workers should be clear and precise.

Case Report: 04CA011

A 35-year-old Hispanic machine operator died when he was caught between a tension roller and conveyor belt at work. The victim was attempting to remove some cardboard from the bottom of a conveyor belt when he got caught in the tension roller. The company’s Lockout/Tagout procedure was not in use at the time of the incident, and there was no guarding to protect employees from the moving parts of the machine. The CA/FACE investigator determined that in order to prevent future occurrences, employers, as part of their Injury and Illness Prevention Program (IIPP), should:
  •  Ensure employees follow lockout/tagout procedures when servicing a machine.
  •  Ensure employees do not place any part of their bodies into areas where they might become entangled with machinery when it is running.
  •  Ensure all machines are properly guarded to protect employees from moving parts.

Face Report: 98CA004

A 39-year old poultry worker (decedent) died when a feather dryer was turned on and he was struck by and caught in the metal paddles. The decedent had been cleaning out the feather dryer tank for about thirty minutes when the paddle drive motor was started by another employee. The feather dryer was not locked/tagged out and the employer did not have a lock/tag out program. There were no caution signs warning employees of the danger of entering the tank. The entry hatch to the tank was not interlocked to prevent motor startup. The employer did not have documentation for the performance of safety inspections nor for conducting training. The CA/FACE investigator determined that, in order to prevent future occurrences, employers should:
  •  Develop and implement formal lockout/tagout programs which include an energy control procedure.
  •  Install interlocks on the hatches of such tanks to prevent startup during maintenance.
  •  Place caution signs to warn employees of the potential hazard of entering such tanks without proper lockout/tagout.
  •  Develop training programs that address lockout/tagout, energy control, interlocks and caution signs.

Investigation: #03CA003

A 44 year-old Hispanic male apprentice mechanic died when crushed by the hydraulic mechanism of a machine that stacks wooden pallets. At the time of the incident, the victim had the door open that guards the movable hydraulic mechanism and was adjusting the settings on the pallet stacker. The Lockout / Tagout procedure was not being used by the victim when the incident occurred. The victim had not completed his safety training. The CA/FACE investigator determined that, in order to prevent future occurrences, employers, as part of their Injury and Illness Prevention Program (IIPP) should:
  •  Ensure that the lockout / tagout procedure is implemented whenever maintenance or repairs are being performed on pallet stacking machines.
  •  Ensure apprentice mechanics are trained on machine operation and safety prior to hands-on work.

Investigation: #98WA06301

On March 9, 1998, a 24-year-old night-shift foreman (the victim) died of injuries when he fell approximately 13-15 feet from a piece of equipment known as a "hay de-stacker". The victim had been trying to clear a "jammed" hay bale on top of the de-stacker when he was pinned in the machine's sweep arm mechanism. After some effort, his fellow employees released him from the machine, but the hay bales that he had been standing on collapsed and he fell head first, landing on the steel decking of the bale staging platform. Emergency medical persons responded and transported the victim to an area hospital, where he later died from head injuries suffered in the fall.

To prevent future similar occurrences, the Washington State Fatality Assessment & Control Evaluation (FACE) Investigative team concluded, that persons working with machinery, should follow these guidelines:
  •  A Lockout/Tagout program should be instituted to protect employees from hazardous energy when working on machines, equipment or processes.
  •  Anytime an individual has a need to work on a piece of machinery or equipment, then that piece of machinery or equipment must be shut down, turned off and locked out.
  •  Employers should provide training and education related to the hazards of energized equipment, provide an understanding of the equipment safeguards and the basics of lockout/tagout.
  •  Routine audits/inspections should be performed on the facility's "Energy Control Program / Lockout-Tagout Program".
  •  When new, used or reconditioned equipment is introduced to the work place, a review of safety precautions should be conducted in conjunction with the equipment manufacturer. The review should include any and all regulatory compliance parameters that apply to the equipment and the operation of the equipment.
  •  Safe access should be provided, such as ladders, platforms, etc. with appropriate fall prevention/fall protection measures, to allow operators to effectively deal with equipment/machine issues.

Case Report: 05WI054

On August 2, 2005, a 55-year-old Maintenance worker (the victim) was pinned between an overhead bridge crane and a roof truss. The victim was part of a two-man maintenance team that ascended 20 feet up a ladder and climbed onto a 30-ton Whitney bridge crane. The victim and another maintenance man were going to adjust the brakes on the 5-ton hoist on the crane. While the operator of the Whitney crane had his back turned from the controls, a second operator came over and moved the crane. He did not know that the victim and another maintenance man were working on the crane above. The first operator realized what was happening and yelled to stop the movement, but it was too late. Management notified the Emergency Medical Services (EMS) at 8:28 a.m. EMS arrived at 8:31 a.m. The conditions the rescue personnel worked in included extreme heat, poor illumination, noise, and the accident site that was located over 25 feet above them. The FACE investigator concluded that to help prevent similar occurrences, employers should:
  •  Ensure that employees follow proper lockout tagout procedures on machinery before performing any repair, maintenance, or adjustments.
  •  Ensure that the employer conducts annual or more frequent inspections of the energy control procedures.
  •  Ensure that all controls are placed at the off position when adjustments and repairs are started on cranes.
  •  Ensure that warnings or “out of order” signs are placed on the cranes as well as on the floor beneath or on the hood where they are visible from the floor.

FACE Investigation: 96MN001

Two employees of a commercial steam heat supplier died of injuries they sustained when a steam line they were repairing was re-Energized. The day before the incident, the two victims and a co-worker went to an underground vault to investigate a steam leak. They suspected that the leak was from a flange in a steam line that served as an interconnect line between two steam generation facilities. The next morning, they told the facility 1 operator that they were going to facility 2 to shut down the leaking steam line before repairing it. At facility 2 they closed two control valves to isolate the leak in vault A. They did not Lockout and Tagout either of the control valves.

After closing the valves, they drove to the site of the leak and began to mechanically ventilate the vault. While the vault was being ventilated, they went to vault B and closed a second isolation valve. They returned to the site of the leak (vault A) and entered the vault after the steam was cleared from it. They confirmed that the leak was due to a defective flange gasket and disassembled the steam line flange.

The repair task was slowed for several hours since the workers initially did not have the correct size wrenches for the flange bolts. They were also delayed when the disassembled line became misaligned as it cooled. Because of the delays and the need for alignment pins to reassemble the line, the workers stopped for lunch and returned in the afternoon to finish the repair.

When the workers returned, the two victims entered vault A while the co-worker remained above ground near the entry to the vault. While the two victims realigned the steam line flanges, the facility 2 operator started a boiler in preparation for a boiler test. He contacted the facility one operator to determine the status of the steam line repair work. He apparently understood that the repair work had been finished and that the interconnect line could safely be re-Energized to provide additional steam for the boiler test. A facility 2 Maintenance engineer opened both control valves and released steam into the interconnect line and the vault where the two victims were working. Both victims were able to escape from the vault within seconds after the steam entered the vault. The co-worker who had been outside the vault, called facility 1 by radio and requested immediate emergency medical assistance. Both victims were transported to a local hospital where one of them died approximately one week later and the other died three weeks later. MN FACE investigators concluded that to reduce the likelihood of similar occurrences, the following guidelines should be followed:
  •  Employers should develop, implement and enforce a written safety program which includes task-specific training and lockout/tagout procedures; and
  •  Employers should ensure that when more than one employee is exposed to hazardous energy, a procedure is in place for group lockout/tagout.

FACE Report: 99MA070

On December 22, 1999, a 36-year-old male second shift foundry manager (the victim) was fatally injured while cleaning the die of a cold chamber die cast machine. The foundry's quality control inspector had notified the victim that one of the die cast machines was producing castings with a blemish on the exterior surface. The victim entered the machine operating area and leaned in-between the two sections of the die to clean them. The machine cycled to the closed position bringing the two sections of the die together while he was still in-between them. The city police and fire departments were notified immediately and arrived within minutes securing the scene of the incident. The medical examiner was notified and upon arrival at the incident site pronounced the victim dead. The MA FACE concluded that to prevent similar occurrences in the future, the employer should:
  •  Enforce a comprehensive lockout/tag out program and constantly review and update the program and training.
  •  Ensure that new safety devices are installed properly and are effective before implementing them.
  •  Obtain information from the die cast machine manufacturer on the proper way to controlling hazardous energy when purchasing a used or remanufactured machine.

Case Report: 05CA006

A 52-year-old Hispanic supervisor died when he was crushed in a machine used in manufacturing concrete blocks. Evidence suggests that the victim had climbed on top of the machine, possibly to reconnect an air line. The victim did not shut the machine down and lock and tag it out prior to climbing on top of it. The skip hoist had dumped product into the hopper portion of the machine and was on its down cycle when the incident occurred. There were no guards in place to prevent the victim from climbing on the machine while it was running. The CA/FACE investigator determined that, in order to prevent future occurrences, employers, as part of their Injury and Illness Prevention Program (IIPP), should:
  •  Ensure employees follow the proper lockout/tagout procedures on machinery before performing any repair, maintenance, connection, or adjustments.
  •  Ensure employee safety by installing guards around the moving parts and pinch points of the machine to protect employees from accidental contact.

In addition:
  •  Manufacturers should design and employers should retrofit machinery so that a worker can remotely turn parts of a machine on or off while the machine is operating.

Case Report: 06CA007

A 43-year-old Hispanic electrician was electrocuted while repairing a lighting circuit that had been damaged by a Contractor doing building renovations. The victim was installing a temporary feed to replace wires that had been damaged when the incident occurred. The victim was instructed by his supervisor to shut off the power to the circuit at the junction box before working on it. The power had not been shut off and no Lockout/Tagout had been applied. The CA/FACE investigator determined that in order to prevent future occurrences, employers, as part of their Injury and Illness Prevention Program (IIPP), should:
  •  Ensure that workers follow established lockout/tagout procedures for control of hazardous energy when working on electrical circuits.

FACE Report: 95NJ108

On November 7, 1995, a 21-year-old machine operator was killed in an industrial baling machine at a recycling center. The incident occurred as the victim and a group of laborers were compacting and baling discarded newspapers for recycling. When the machine jammed, the victim entered the machine's compacting chamber and was pulling out the excess newspaper when a co-worker accidentally activated the compactor, crushing the victim. FACE investigators concluded that, in order to prevent similar incidents in the future, these safety guidelines should be followed:
  •  Employers should ensure that company lockout/tagout procedures are followed.
  •  A procedure should be established that clearly describes the methods to clear jams in the baler.
  •  Safety interlocks should be designed to immediately shut the machine down when activated.
  •  Employers should assess each job for potential hazards and train employees in methods of dealing with them.