Inspection Detail

Inspection: 119722056 - The Pacific Lumber Company

Inspection Information - Office: American Canyon District Office

Investigation Summary

Between 11:40 p.m. and 12:00 p.m. on September 8, 1992, Employees #1, #2, and #3 were at the hardwood chipping mill at a logging and sawmill operation run by the Pacific Lumber Company, entered a drum debarker to clear an obstruction that was jamming the drum, according to circumstantial evidence. There were no witnesses. Evidence shows that the employees did not lock out the debarker before they entered it, but used the control switch in the outfeed Barko to shut off the machine; the outfeed operator may have forgotten to hit the stop button for the already stopped drum, which then began to rotate when the jam was cleared. Another possibility is that it may have been stopped initially to clear a jam and one of the employees turned it on to test it; finding it still jammed, he forgot to shut it off when the three employees re-entered the debarker to clear the jam. With the switch on and the unit not locked out, the hydraulically-operated drum will rotate; once rotating, the logs would inflict fatal injuries in seconds. Employees #1 through #3 were at the infeed end of the unit and had no chance to escape; the only way out is through the drum or up a steep chute. They were killed. Although the company has good lock out procedures and training, employees were not in the habit of locking out when going in to clear a jam in the debarker. A serious citation for a violation of T8CCR 3314(a) was issued to the employer for failure to lock out.

Keywords: MAINTENANCE, LOG, WORK RULES, JAMMED, LOCKOUT