Hay Press Operator Struck by Machine’s Guillotine Blade

Details

• Corporate Authors:
  Washington (State). Department of Labor and Industries
• Description:
  On February 9, 2018, a 39-year-old hay press operator died when he was struck by the machine's steel guillotine blade. The operator was performing his usual job duties at a plant that processed field baled hay into high-density bales for shipping. Near the end of his work shift, the plant supervisor asked the operator and two other employees to prepare the machine for scheduled maintenance. The shift supervisor was at the machine's control panel waiting for a signal from the operator to turn off the machine's power. During normal operation, a conveyor moved hay into the main press where a scale and guillotine were located. When the hay reached the correct weight, the scale triggered the guillotine that sliced off a section of the hay to be compressed. The operator crawled into the hooded intake opening of the main press to push a bale through to clear the area of remaining hay. No one noticed him get into the energized machine. As he was lying on the scale, the guillotine activated and struck him, resulting in near decapitation. He was pronounced dead at the scene. CONTRIBUTING FACTORS: Lockout/tagout (LOTO) procedures not followed. LOTO training not provided to all employees working on or near energized equipment. Recurring employee deviation from LOTO procedures not reported. Hazardous energy control program evaluations not conducted by management. RECOMMENDATIONS: Washington State Fatality Assessment and Control Evaluation investigators concluded that to protect employees from similar hazards employers should: Enforce and evaluate employee compliance with machine manufacturer's LOTO requirements when servicing or maintaining machines and equipment. Provide and enforce LOTO training that emphasizes the severity of the hazard of entering energized machines that have LOTO requirements. Implement, enforce, and evaluate a hazard reporting and response system that can document employee deviations from LOTO requirements and initiate corrective actions when they reoccur. Perform risk assessments with the machine manufacturer to understand or customize safety control system features, such as emergency stop (E-Stop) locations and access doors. [Description provided by NIOSH]
• Subjects:
  Environmental Exposure Mortality Occupational Health Risk Assessment Risk Factors Safety Staff Development Workplace
• Keywords:
  Exposure Levels Fatalities Hazards Lockout Tagout Protective Measures Risk Factors Safety Education Safety Measures Safety Practices Training Work Environment Workers Worker Safety

  More +
• Publisher:
  Washington State Department of Labor and Industries
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Report
• Place as Subject:
  OSHA Region 10 ; Washington
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  1-14
• NIOSHTIC Number:
  nn:20063704
• Citation:
  Olympia, WA: Washington State Department of Labor and Industries, 52-49-2021, 2021 Oct; :1-14
• Federal Fiscal Year:
  2022
• Performing Organization:
  Washington State Department of Labor and Industries
• Peer Reviewed:
  False
• Start Date:
  20050701
• Source Full Name:
  Hay press operator struck by machine's guillotine blade
• End Date:
  20260630
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:c53b956a00a6a835edf91453d04454d51a86ab2de29a2d618255a9d22ad83f4d6326ba1260af9ed83f54d96a81fa8e2c490a42949ece43c62707d7a65f4e7581
• Download URL:
  https://stacks.cdc.gov/view/cdc/222265/cdc_222265_DS1.pdf
• File Type:
  [PDF - 1.23 MB ]