Date of incident: May 2023
Notice of incident number: 2023194050007
Employer: Wood and gas stove manufacturer

Incident summary
A young and new worker at a manufacturing warehouse was using a brake press machine to bend pieces of sheet metal. The brake press had a lower bar, referred to as the die, that would move upward to meet an upper bar, called the punch. The punch and die would come together, creating a small pinch point known as the hazard zone, where the metal was bent. The worker was realigning a metal piece in the hazard zone when he became caught between the punch and die. He sustained serious injuries.

Investigation conclusions

Cause

• Worker caught in brake press. While the worker was realigning the metal piece, he reached into the hazard zone of the energized brake press, in the 3.2 cm (1¼ in.) space between the punch and die. The worker inadvertently pressed the foot pedal that brought the punch and die together, which caused the punch and die to close on him.

Contributing factors

• Inadequate safeguarding. The safeguarding controls put in place by the employer inadequately protected workers using the brake press. The placement of the safeguarding and the inadequate oversight of the safeguarding allowed the worker to enter the hazard zone.
• Failure to follow manufacturer specifications and standard operating procedures. The employer did not follow the manufacturer’s specifications on setting a safe amount of space between the punch and die. The established safe space of 6 mm (¼ in.) was required to prevent the operator from entering the hazard zone. Based on the manufacturer’s specifications, the employer developed a standard operating procedure (SOP) to ensure that operators were not entering the hazard zone but did not follow its own SOP. The operator’s manual also specifies how operators should hold metal pieces when bending, but the employer did not reinforce this specification with the creation of an SOP.
• Inadequate instruction and supervision of young and new worker. While the worker had been given adequate on-the-job training, other components of his training were incomplete. The employer did not ensure that the worker completed all the required online training modules before starting as a brake press operator. The employer also allowed him to use a safeguarding system that permitted him to reach into the hazard zone of the brake press. The worker was not provided with adequate instruction or orientation to the work process and was not being supervised while performing his duties. In addition, the employer did not ensure that the workers had read the operator’s manual.

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