Inspection Detail

Inspection: 1506019.015 - Spartan Light Metal Products, Inc.

Inspection Information - Office: Fairview Heights Area Office

Investigation Summary

At about 10:00 p.m. on December 4, 2020, an employee was working for a nonferrous metal diecasting foundry. He was a machine operator. He was in the operations part of the facility. He and a coworker were changing mold plates on the B�hlerPrince DCM065 cell number 56 1400TT Cc diecast machine. Power to the machine had been shut off at the electrical disconnect. As the two were connecting hydraulic lines, they ran into complications. They couldn't make a connection, so they tried clearing debris from the hydraulic line quick connect couplers. They continued to experience issues. Their next step was relieving pressure on the lines by draining hydraulic fluid that was pressurizing the machine. At approximately 10:30 p.m., the coworker went to manually drain hydraulic fluid from the machine's accumulators. As the coworker performed this operation, the employee placed his left hand inside and on the edge of a locking-pin hole on one of the mold plates. He did this to maintain his balance while he used a tool to break the hydraulic line with the malfunctioning connector loose from the machine. When the employee removed the hydraulic line from the machine, the pressure that was holding the mold's slide core in an elevated position fell. The slide core as well dropped and closed, and the small, ring, and index fingers of the employee's left hand were crushed. The employee was taken to a major hospital in St Louis MO. He was hospitalized. His three crushed fingers were surgically amputated. Established lockout/tagout procedures were not followed for performing service on the machine. The release of the stored pressure caused the employee to be exposed to movement of the slide core.

Keywords: Amputated, Amputation, Caught In, Connecting, Connector, Crushed, Die, Die Casting Machine, Falling Object, Finger, Hand, Hose, Hydraulic, Hydraulic Cylinder, Hydraulic Fluid, Hydraulic Line, Lockout, Lockout/Tagout, Misjudgment, Misjudgment of Hazardous Situation, Mold, Mold Plates, Pressure, Pressure Release, Supervision, Surgical Amputation