Inspection Detail

Inspection: 119802189 - Tri Valley Growers Plant 7

Inspection Information - Office: American Canyon District Office

Investigation Summary

On September 2, 1995, Employee #1, an MCC mechanic at Tri Valley Grower, plant 7, Modesto, CA, has worked for the company for 18 years. Shortly after his shift began at 10:00 p.m., a coworker, a bracket 3 mechanic's helper, informed Employee #1 that he and two other employees were having trouble putting the chain back on the elevator unit that conveys cans from the cooler to the palletizer. Employee #1 got on the platform that provides access to the chain and sprocket drive and asked the bracket 3 mechanic to make sure the power was off and the equipment locked out. Once the coworker said this was done, Employee #1 started to re-lace the chain, using his left hand and thumb to hold the chain against the sprocket. When he had laced the chain around two of the three drives, he turned to get his screwdriver out of his back pocket and observed the palletizer operator energizing the elevator. Employee #1's left thumb was caught in the chain and sprocket and severed at the first joint. Causes of the accident include: (1) the bracket 3 mechanic's failure to lock out the elevator at the lockable switch; (2) the bracket 3 mechanic's failure to install accident prevention signs or tags on the main control box at the palletizer and on the lockable switch on the elevator; and (3) Employee #1's failure to physically check to see if the equipment was properly secured and locked out before beginning work. A lockout switch was close to where he was working and would have been easy to check.

Keywords: CHAIN, AMPUTATED, REPAIR, WORK RULES, CAUGHT BY, THUMB, LOCKOUT, CONVEYOR, SPROCKET, COMMUNICATION