Inspection Detail

Inspection: 111896809 - Sierra Pacific Industries

Inspection Information - Office: Redding District Office

Investigation Summary

At approximately 10:00 p.m. on July 27, 1990, Employee #1, a millwright for Sierra Pacific, Quincy, CA, went to the hog in the sawmill. The screen had dropped and he was to weld an eye on the inside wall of the hog, attach a come-along to the eye and then to the screen below, and pull it back up into position. The hog was turned off and he attached his lockouts to the electrical disconnects for the hog, the conveyor, and the auger. The rotor had to coast to a stop, which takes approximately 40 minutes. There is a large sign above the hog door that reads "Lockout required -- do not open hood on door until rotor has stopped." According to other millwrights interviewed, the door is not opened until the rotor stops. Employee #1, however, turned the welder on, went up onto the platform where the hog door is located, took the two T-bolts out of the door, asked the saw filer, who was standing on the lower platform, to hand him the welding lead, opened the door, and either stepped into the hog to start welding or, somehow, fell in. The rotor had not come to a complete stop and the employee went through the hog. He died. From the interviews conducted, Employee #1 was known for being safety conscious and encouraged others to do their jobs safely, even reminding them to be sure to lockout. The night of the accident, the mill had been plagued with breakdowns and clogs. It cannot be determined whether Employee #1 was trying to rush the job by opening the door before it stopped or forgot to check to make sure the rotor had stopped because he had his mind on something else. No one anticipated or had knowledge that the hog door would be opened prior to stopping.

Keywords: WORK RULES, LOCKOUT, MILLWRIGHT, SAWMILL