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Worker's hand crushed in unguarded machine rolls

Date of incident: January 2014
Notice of incident number: 2014166970013
Employer: Metal fabrication company

Incident summary
A steel fabricator was preparing a metal forming roll machine to bend food-grade stainless steel. To prepare the machine, the worker placed cardboard around each of the machine's three rolls. To do this, the worker had the machine powered on to rotate the rolls. As the worker was applying cardboard to a bottom roll, one hand and wrist were inadvertently drawn into the in-running nip point. The worker suffered severe crushing injuries to his hand.

Investigation conclusions
Cause

  • Equipment without safeguards was energized during preparation: The worker was wrapping the machine rolls with cardboard while the equipment was energized. One hand and wrist were caught in the unguarded in-running nip point between the operating top and bottom rolls.

Underlying factors

  • No lockout: The employer did not ensure that its lockout procedures were in use for the work of preparing the machine rolls. The lockout program did not explain how to lock out any of the equipment at the workplace.
  • Lack of training with food-grade stainless steel: This was the first time the worker was assigned to work with food-grade stainless steel. He was not provided with any training on how to safely prepare the rolls.
  • Inadequate supervision: The employer introduced a new procedure for the worker to follow to prevent contaminating the food-grade stainless steel during production but did not provide any supervision to ensure he could safely conduct the procedure. The worker was assigned to work alone to install cardboard to each of the three rolls. No proper supervision was provided while this new task was conducted. Additionally, the worker was permitted to work on the machine without following or referring to the manufacturer's instructions.
  • No instructions provided: This was the first time the worker was involved with modifying the machine in this manner. The employer did not provide the worker with any instructions on how to safely modify the rolls.
  • No hazard assessment and safe work procedure: No hazard assessment was done for modifying the rolls; therefore, no written safe work procedure was created. The employer did not conduct a hazard assessment to identify risks and did not determine how to install cardboard onto the rolls in such a way that no workers would be put at risk.

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Publication Date: Jan 2014 Asset type: Incident Investigation Report Summary NI number: 2014166970013