Inspection Detail

Inspection: 110420213 - Stone Container Corporation

Inspection Information - Office: Baton Rouge Area Office

Investigation Summary

EMPLOYEES WERE PARTICIPATING IN A "FIELD DAY," A PRESCHEDULED MONTHLY EVENT IN WHICH PLANNED MAINTENANCE WORK IS PERFORMED ON PAPER MACHINES, AND WERE WORKING ON PAPER MACHINE #5. THE BREAST ROLL WOULD NOT GO ALL THE WAY DOWN AND A MAINTENANCE EMPLOYEE WAS CALLED TO WORK ON THE PROBLEM. AT THE SAME TIME, EMPLOYEES #1 AND #2 WERE CHANGING THE BEARINGS ON WIRE RETURN ROLL #8. NEITHER SET OF EMPLOYEES WERE AWARE OF THE WORK BEING PERFORMED BY THE OTHER. IN THE PROCESS OF THE MAINTENANCE EMPLOYEE BREAKING THE COUPLING THAT CONNECTED THE AIR MOTOR TO THE GEAR BOX, WHICH IS THE MECHANISM THAT ACTIVATES THE CROSS SHAFT THAT RAISES AND LOWERS THE BREAST ROLL, THE GEAR BOX UNEXPECTEDLY FREEWHEELED. THE BREAST ROLL WAS ALLOWED TO MOVE DOWNWARD, SWEEPING EMPLOYEES #1 AND #2, WHO WERE WORKING ON THE WIRE RETURN ROLL, INTO THE ROLL. THEY WERE PINNED BETWEEN THE BREAST ROLL AND WIRE RETURN ROLL #8. BOTH DIED AS A RESULT OF THIS ACCIDENT.

Keywords: PINNED, WORK RULES, PAPER ROLL, LOCKOUT, ROLLER--MACH/PART, CAUGHT BETWEEN, PAPER MACHINE, INATTENTION