Inspection Detail

Inspection: 125947010 - Alcoa Fastening Systems

Inspection Information - Office: Santa Ana District Office

Investigation Summary

On October 14, 2005, Employee #1, a machining technician with an aerospace fastening systems manufacturer, was operating a Wilton automated Drill Press (Number 2825). This press was used for beveling round aircraft fasteners (30 mm outside diameter, 15 mm inside diameter, and 15 mm high). Employee #1 picked up a fastener with an extension tool and placed into the drill chuck for beveling. She then activated the beveling process by simultaneously placing both hands on the machine safety trip pads. At that time, the beveling bit came down, failed to make contact with the fastener, and retracted up to its start position. She repeated the process, however, the press malfunctioned and stayed in the start position. When Employee #1 noticed that the fastener was positioned upside down, she released the chuck pressure, and tried unsuccessfully to remove the fastener with an extension tool. Assuming the malfunctioning press would not reactivate, Employee #1 attempted to remove the fastener again by placing her right index finger in the center of the fastener. When the press activated unexpectedly, the countersink bit came down and amputated her finger between the first and second joint.

Keywords: AMPUTATED, FINGER, INTERLOCK, EQUIPMENT FAILURE, JAMMED, POINT OF OPERATION, DRILL PRESS, EXTENSION HANDLE, PRESS OPERATOR, PRESS