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Young worker sustained fatal injuries when press cycled

Date of incident: August 2013
Notice of incident number: 2013155980209
Employer: Manufacturer of recycled-rubber products

Incident summary
A young worker was operating a press to create rubber blocks. The work procedure required the worker to reach into the press to reposition any excess rubber material back into the centre of the mould. The worker was most likely performing this task when the press unexpectedly closed onto him. The young worker suffered fatal injuries when he was crushed by the press.

Investigation conclusions

  • Press cycled while worker reached into aperture: The aperture is the area between the moving parts of the power press that workers can reach into while the press is operating. The press cycled while the young worker was in the aperture, most likely to move excess granular rubber back into the centre of the mould. The young worker received fatal injuries as the upper platen of the press moved down onto him.
Underlying factors
  • Work procedure placed workers at risk: The work procedure required workers to reach into an unguarded area of the presses several times during a normal production cycle. As a result, workers were exposed to pinch points in each of the seven presses at this workplace.
  • Press safeguarding was inadequate: Workplace hazards were created during the production of rubber blocks at this workplace. Press operators were exposed to potential pinch points while the presses were operating, due to the following deficiencies:
    • Inadequate machine guarding: The power press involved in this incident was not guarded in accordance with regulatory and industry standards.
    • Inadequate lockout procedures: Lockout procedures had not been established to address the work being performed at the time of the incident.
  • Substandard press controls: The controls for the press, specifically the raise-upper-platen button, were not in accordance with the required standard (CSA Standard CAN/CSA-Z142-M90), permitting the machine to continue operating automatically without a separate action by the press operator.

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Publication Date: Aug 2013 Asset type: Incident Investigation Report Summary NI number: 2013155980209