Inspection Detail

Inspection: 111846077 - Flow Master

Inspection Information - Office: American Canyon District Office

Investigation Summary

At approximately 10:30 a.m. on July 30, 1991, Employee #1 was stamping small sheet metal parts on an open-back incline punch press equipped with a full revolution clutch. To increase his production speed, Employee #1 installed an elastic bungee cord on the right side of the two-handed trip device. This allowed the machine to be activated by pressing the left side switch. Just before the accident, Employee #1's supervisor came by to check his progress. The supervisor observed normal operating procedures. After this time, Employee #1 changed the dies so he could make a slightly smaller piece. The smaller die was equipped with a spring that did not always help to release the stamped piece. Customarily, an extension tool is used to remove a piece that is not fully released. Even though a tool was available at his work station, Employee #1 did not use it to remove the piece. Employee #1 put the bungee on the right side when he changed the dies so he could free his right hand. When a stamped piece lodged in the die, Employee #1 turned off the electrical power to the motor (left side), then reached into the open die to remove the sheet metal with his right hand, unaware of the still spinning flywheel. With the right trip already held down, the left trip was contacted and the remaining energy stored in the revolving flywheel was sufficient to cycle the press. Employee #1's right hand was crushed. His right index finger had to be surgically removed between the second joint and the hand, leaving approximately a 1/2 in. stub.

Keywords: AMPUTATED, FINGER, WORK RULES, TWO-HAND CONTROL, CRUSHED, PRESS OPERATOR, PUNCH PRESS, HAND, PRESS