Fatality Assessment and Control Evaluation (FACE) Report for Michigan: Co-Owner of Metal Forge Shop Dies When an Ejected Piece of Steel Used as a Stop Block in a Full Revolution Press Strikes Him in the Chest.

摘要

On April 3, 2003, a 62-year old forging company co-owner died when a solid metal cylinder he had placed on the stripping plate of a full-revolution press struck him in the chest when the press cycled. The firm was initiating a new operation - trimming a rubber boot to protect steering linkages from dirt and other contamination. The die set had been purchased from the company from which the forging company had previously outsourced this operation. The forging company did not purchase the press in which the die set was used. The victim installed the die set in the 'bender' press; a full revolution press (See Figure 1). The 'bender' was selected because the bed size of the 'bender' was appropriate for the die set. One rubber boot trim run had been performed, but the boot was not completely trimmed; hand trimming was necessary. The victim placed a piece of solid, cylindrical steel, measuring 4 inch long, 1 7/8 inch diameter on the front edge of the die stripping plate to act as a stop block. The victim activated the 'bender' by pressing the dual palm buttons without removing the steel cylinder. He may have sat down in front of the press on a stool. When the ram came down, it contacted the cylindrical piece of steel. When the ram contacted the steel, it caused the stripping plate to unevenly depress at an angle toward the victim instead of horizontally. This caused the piece of steel to be forcefully ejected from the press and strike the victim in the chest. The co-owner working in a different shop area heard two loud noises, turned, and saw the victim fall to the ground. Another worker called 911 while the co-owner initiated CPR. Emergency response arrived and transported the victim to a local hospital where he died. Recommendations: (1) Install an electrically integrated safety block and barrier guard to permit safe work operations. (2) Conduct a task analysis and develop task-specific safe work procedures when beginning new work to identify potential safety issues and solutions. (3) Ensure 2-hand trip buttons are the appropriate distance from the work operation. (4) Although not a factor in this death, MIFACE recommends that after a new operator is assigned to a press, employers complement the 8 hours of press operator training recommended by Federal OSHA by extending the period of time the new operator works under the close supervision of an experienced operator to enable the new operator to understand the interaction between the press, die, and product.