Inspection Detail

Inspection: 120223722 - The Sacramento Bee

Inspection Information - Office: Sacramento District Office

Investigation Summary

At about 10:00 a.m. on Friday, January 6, 1995, Employee #1, of the Sacramento Bee packaging department, was one of a dozen or so employees working around paper inserting machine #1, a large carousel type machine with about 22 insertion heads or possible work stations that places ads and periodicals into the daily papers. When the machine started running, one insertion head was not adjusted properly and was dropping a single sheet atop the rotating carousel, clogging the workings three stations down from where Employee #1 was inserting. The machine was turned off by the supervisor and two inserters and the supervisor removed the "floaters" (the insertions that were lying atop the carousel clogging the works). The supervisor was the only one to push the STOP buttons. There is a STOP button at each insertion head with a light to show where the machine is stopped; the machine cannot start until all STOP buttons are removed and the lights are off. Once the floaters were removed by the supervisor and the inserters, the supervisor started the carousel, which rings a warning bell before starting. He was unaware that Employee #1's arm was still in the machine; she was removing a floater without having pushed her STOP button. When the machine started, her arm was pulled back against the side guard area. She was taken to the office by the supervisor and an ambulance was called, which transported her to Sutter General Hospital, Sacramento, CA, where she was admitted with a lacerated and broken arm.

Keywords: FRACTURE, WORK RULES, CAUGHT BY, LOCKOUT, LACERATION, ARM, COMMUNICATION, INATTENTION