A Foreman Dies When He is Crushed in a Hay Baling Machine

Details

• Personal Author:
  Cierpich, Hank ; Harrison, Robert ; Styles, Laura
• Corporate Authors:
  California Fatality Assessment and Control Evaluation Program (CA/FACE) ; California. Department of Public Health. Occupational Health Branch
• Description:
  A foreman was crushed in a hay baling machine while he was clearing debris out of the machine. The foreman went through a gate with sensors that were designed to shut the machine off while he entered the area that moves the compacted bales. While the foreman was clearing the debris, he was crushed between moving parts of the machine. Testing on the gate sensors after the incident showed that they were working properly. The employer did not have an Injury and Illness Prevention Program (IIPP), and there was no lockout/tagout system in place at the time of the incident. The CA/FACE investigator determined that, in order to prevent future incidents, companies that process and bale hay should: 1) Develop and implement safety and training programs for employees that include hazard evaluation, formal training, supervision, and communication. 2) Develop and implement a comprehensive hazardous energy control program including a lockout/tagout procedure and training. CONTRIBUTING FACTORS: Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger sequence of events that ultimately result in an injury or fatality. The CA/FACE team identified the following contributing factors in this incident that ultimately led to the fatality: 1) Unclear communication between machine operator and victim. 2) No lockout/tagout program. 3) No safety or training program. RECOMMENDATIONS: To prevent future incidents, companies that process and bale hay should: a) Recommendation #1: Develop and implement comprehensive safety and training programs for employees that include hazard evaluation, recognition, formal training, supervision, and communication. b) Recommendation #2: Develop and implement a comprehensive hazardous energy control program including a lockout/tagout procedure and training.
• Subjects:
  • Agriculture
  • Automobiles
  • Hazardous Substances
  • Manufacturing and Industrial Facilities
  • Mortality
  • Occupational Health
  • Safety
  • Safety Management
  • Staff Development
• Keywords:
  • OSHA Region 9
  • Mortality-data
  • Injuries
  • Injury-prevention
  • Traumatic-injuries
  • Agricultural machinery
  • Lockout tagout
  • Machine operation
  • Machine safety
  • Industrial hazards
  More +
• FACE - NIOSH and State:
  FACE ; Machine (All) ; Machine - Manufacturing
• Series:
  Fatality Assessment and Control Evaluation Reports (FACE)
• Subseries:
  State
• DOI:
  https://doi.org/10.26616/NIOSHSFACE16CA002
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Field Study
• Place as Subject:
  California ; OSHA Region 9
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  1-11
• NIOSHTIC Number:
  nn:20050026
• NTIS Accession Number:
  PB2017-102694
• Citation:
  Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 16CA002, 2016 Dec ; :1-11
• Federal Fiscal Year:
  2017
• Performing Organization:
  California Department of Public Health
• Peer Reviewed:
  False
• NAICS and SIC Codes:
  42 - Wholesale Trade - (NAICS)
• Start Date:
  2005/07/01
• End Date:
  2026/06/30
• Resource Number:
  FACE-16CA002
• Download URL:
  https://stacks.cdc.gov/view/cdc/165002/cdc_165002_DS1.pdf
• File Type:
  [PDF - 609.70 KB]
• Collection(s):
  Fatality Assessment and Control Evaluation (FACE) Program ; National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:6d4c128eaaa99a1db9309aec4be77425500ac34ab4465acf7794b12b2786dea569669dd972bd417ed9e8890fd9d9660cfbc4ec44322ed08e806011818f13a0fc