Worker's hands crushed in unguarded machinery
Date of incident: December 2013
Notice of incident number: 2013162000416
Employer: Manufacturer of fireplace products
Incident summary
A production worker was using an unguarded press brake in order to bend and shape the top of a fireplace box (the work piece) that would eventually become part of a completed gas fireplace insert. The worker made the first bend without incident. He then attempted to make a second bend but had difficulty ensuring the work piece was lined up correctly in the bottom die.
The worker placed both hands between the top and bottom dies to adjust the work piece. He inadvertently activated the press brake using the pedal control, causing the top die to activate and lower rapidly onto both of his hands, trapping them between the top and bottom dies. The worker kicked the pedal off the end of his foot, and the top die retracted to its up position. The worker experienced crushing injuries to both hands.
Investigation conclusions
Cause
- No point-of-operation safeguarding: The worker placed his hands into the point of operation between the dies of a press brake. This was possible only because there was no point-of-operation safeguarding on the machine to prevent this action. The worker then inadvertently operated the pedal control, which was missing a guard. This activated the press brake, causing it to cycle. The worker suffered crushing injuries to both hands.
Underlying factors
- Lack of safe work procedures: The employer did not provide a safe work procedure to workers using the press brakes. As a result, workers were not trained to safely operate the machines.
- Lack of training and supervision: The employer did not ensure that workers using the press brakes were effectively trained and adequately supervised.
- No point-of-operation safeguarding risk assessment: The employer did not perform a point-of-operation safeguarding risk assessment and implement appropriate point-of-operation safeguarding to protect workers using the press brakes.
- No health and safety program: The employer did not implement an effective health and safety program.