Inspection Detail

Inspection: 109470989 - Specialty Forest Products, Incorporated

Inspection Information - Office: Atlanta West Area Office

Investigation Summary

At around 3:30 p.m. on March 23, 1993, Employee #1 was foreman for a six-man crew that was forming 43 ft roof trusses. He ordinarily supervised an average of nine employees, performed routine maintenance on equipment, and acted as an equipment operator when a crew member was absent from work. That day, the crew was short two men so the owner was helping out. Employee #1 was operating the truss roller machine on the input side. The owner, who was separated from Employee #1 by the two rollers, was standing on the receiving side. When the truss was halfway through, Employee #1 stopped the rollers because a cleat was falling off. He replaced the cleat and restarted the equipment. The machine stopped again, with about 40 ft of the truss through the rollers. At this point, cleats do not normally fall off. The owner looked back, did not see Employee #1, and concluded that the equipment had jammed. Because there were only 3 ft of truss left to finish, the owner restarted the equipment. He was unaware that Employee #1 was bent down behind the rollers. The owner saw an arm come through the rollers and quickly hit the reverse button. Employee #1 had been caught in the rollers and died at the scene. There was no ingoing point of operation guard used and a trip bar was present only on the receiving side.

Keywords: WORK RULES, INTERLOCK, ROLLER--MACH/PART, INEXPERIENCE, NIP POINT, COMMUNICATION, UNGUARDED, INATTENTION