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Home » Lockout Resources » NIOSH Documentation » Select Case Summaries » Worker Fatally Injured by Steel Blade While Cleaning a Dough Machine

Worker Fatally Injured by Steel Blade While Cleaning a Dough Machine

New York, Case Report: 02NY096


On December 21, 2002, a 54 year-old Taiwanese male food production worker, who was employed by a pizza dough manufacturing facility, sustained fatal injuries as a result of deep neck lacerations made by a steel blade on a dough machine. On the day of the incident, the victim and a co-worker were assigned to clean two dough machines, an “elevator” and a “divider”. The “elevator” had three major components: a lifting mechanism, a hopper, and a steel blade (“dough chunker”) that was located at the bottom of the hopper. The facility’s Lockout/Tagout procedure required an operator to set the control buttons of the “dough chunker” to “Off” and “Manu” before turning off the main power switches. Prior to the incident, the victim turned off and locked the power switches, but left the “dough chunker” controls set to “On” and “Auto”. The victim and the co-worker then proceeded to clean the machines. At approximately 4:15 PM, the co-worker was ready to clean the dough bowl on the “elevator”. In order to clean the outside of the bowl, he had to have the bowl raised by the “elevator”. He went to the victim and asked him for the key to unlock the main power switch to the “elevator”. At this point the victim was in the middle of cleaning the inside of the “elevator” hopper. He was standing on a metal stair, bending over and extending his head through the bottom opening of the hopper and wiping the inside of the hopper with a rag. When asked, the victim gave his key to the co-worker. The co-worker walked to the control panel, unlocked the main power switch, turned it on, and started raising the bowl. A few seconds later, the co-worker heard noises made by the victim. He immediately pushed the emergency stop button to stop the machine. The co-worker rushed to the victim and saw that the victim appeared to be partially decapitated from behind by the Energized steel blade. The co-worker called the shift supervisor for help. The shift supervisor summoned the paramedics who arrived within five minutes. The victim was pronounced dead at the scene and was transported from the accident site to a local hospital morgue.

New York State Fatality Assessment and Control Evaluation (NY FACE) investigators concluded that to prevent similar incidents from occurring in the future, employers should:

  • Conduct periodic inspections to ensure that company lockout/tagout procedures are being strictly followed;
  • Update the company’s lockout/tagout program to include specific shutting down procedures for the “elevator”;
  • Modify the cleaning procedure to avoid placing the workers’ body into the point of operation;
  • Install interlocks to eliminate possible human errors during machine maintenance and sanitation;
  • Provide immediate employee retraining to ensure that the workers understand the key elements of the lockout/tagout program.

Source: www.cdc.gov/niosh

last modified: December 05, 2013   Printer Friendly   Top