Inspection Detail

Inspection: 120213640 - Kraft General Foods

Inspection Information - Office: Fresno District Office

Investigation Summary

At approximately 1:30 a.m., Employee #1, a trained and experienced machine line technician for Kraft General Foods, was called to repair a Shell conveyor/Rogue cheese machine that had stopped and could not be restarted. When he arrived, he checked the control panel switchology and fuses and found no discrepancies. Employee #1 then proceeded to the belt conveyor, which was powered by a DC motor and chain drive. He visually inspected the unit to determine its condition. According to Employee #1, he then squatted down and placed his right hand on the gear box to support his weight. At this point, the motor started, catching his fingers in the chain drive nip point and amputating his third and fourth fingers at the distal phalanx. Employee #1 was transported to Tulare District Hospital, Tulare, CA, where he was treated and released. Employee #1 failed to follow the employer's lockout procedure. It should be noted that the conveyor's brushes were found to be in bad condition and were replaced. This can be done without removing the motor. The inadvertent start up of the motor may have occurred when Employee #1 pulled on the chain drive to jump start the motor, causing the brushes to contact the commutator.

Keywords: CHAIN, AMPUTATED, REPAIR, INADEQUATE MAINT, JUMP START, FINGER, WORK RULES, LOCKOUT, CONVEYOR, NIP POINT