Inspection Detail

Inspection: 126079912 - Brandon International

Inspection Information - Office: Monrovia District Office

Investigation Summary

.At approximately 10:47 pm., on June 14, 2000, inside the building in the machine area, several machines were stationed on the plant floor. There was ample space on the plant floor for employees to maneuver around each machine. The work areas were maintained fairly tidy. There was adequate lighting in the machine area and the ambient temperature was comfortable room temperature. Employee #1,hired as a general laborer for Brandon International Baldwin Park, CA, was performing tasks that include packing, cleaning of material/parts, checking parts, and B-press operation. Approximately two weeks prior to accident, Employee #1 accepted a new position operating hydraulic punch press machinery. Employee's training for her newly acquired position as a punch press operator consisted of different operators showing her how to operate the machines. During the two weeks prior to the accident, she was assigned to different machines to operate on a daily basis. Employee #2 was the most active employee in terms of showing Employee #1 how to operate the machines. On the night of the accident, she was dye setting on the punch press. This was her first encounter with dye setting at the facility. Previously, she was simply operating a machine whose dye was already set. The punch press was in a dye setting mode, according to work order Number 17183 and interview testimony (from division manager). Dye setting procedure would be time consuming and required some experience and a certain level of skill. Per Employee #1, dye setting usually takes 4-8 hrs to complete. On the night of the accident, Employee #2 instructed Employee #1 to put more tape on the underside of the plate to use as a "shim" to level out the dye cutting plate, then he returned to his own work station. The machine involved in the accident was Preco 1220 hydraulic punch press. The Preco 1220 hydraulic punch press was set up to produce a gasket with a sticky backing. During test runs of the material, the sticky backing on the gasket was causing them to become stuck on the dies inside the nip point of the punch press as the material was rolled out. Employee #1 was instructed by Employee #2 to pull on the gasket material when the press opened. The supervisory key was set on continuous mode. When the Preco is set on "continuous mode", the press continued to cycle once both palm buttons were activated. The only way to stop this automatic and continuous cycling would be to press the stop button. The employee said it was necessary for Employee #1 to run on "continuous mode" so she could pull the material while the jaws were opened during cycling. Per Employee #1, it was impossible to run the 1220 Preco on "single mode" because she needed to pull on the gaskets when the jaw was up. Single mode would required the operator to push two buttons, one for each hand, to cycle the concurrent press, which results in one cycle each time the buttons are pressed at the same time. She never touched the supervisory key. ACCIDENT DESCRIPTION: The 1220 Preco punch press was set on automatic mode using the supervisory key. The feeder to pull the material through the punch press was left turned off during the die setting procedure. Therefore, she used both hands to pull the material through the punch press while it was cycling in automatic mode. When the sticky backing of the gasket material became stuck, it became more difficult to pull through the punch press. On one of the instances when Employee #1 pulled on the gasket, her left hand got too close to the point of operation and got crushed as the jaws of the punch press closed. The injuries sustained were as follows: 1. Severe crush injury of the left middle, ring, and small fingers. 2. Partial amputation of the distal phalanx of the left middle finger. 3. Fracture of the proximal phalanx of the left ring finger, middle phalanx of the left middle and ring fingers, and distal phalanx of the left ring finger. 4. Destruction of the A2 pulley of the left middl

Keywords: AMPUTATED, FINGER, CAUGHT BETWEEN, CRUSHED, LACERATION, POINT OF OPERATION, PUNCH PRESS, HAND