Inspection Detail

Inspection: 1564616.015 - Aerocontrolex

Inspection Information - Office: Cleveland Area Office

Investigation Summary

At 10:34 a.m. on November 11, 2021, an employee was working for a firm that manufactured aircraft parts and auxiliary equipment. She was an assembly production lead. She was operating a Cunningham Manufacturing Co. "C" style hydraulic swaging press, with serial number 91597-214. It had a 6 in (152.4 mm) bore, a 3 in (76.2 mm) piston, and a 9 in (228.6 mm) stroke. She was performing a normal die setup on the press. The employer operated several hydraulic swage presses for manufacturing sliding cables. Six were "C" style hydraulic presses. To make the cables, employees had to switch out dies to perform different operations. Depending on the part, employees might perform between four and ten die changes. During setup, employees turned the lower die piston knob counterclockwise to lower the height adjustment piston until the top of the die adapter was flush with the lower die cup. This ensured adequate clearance between the lower die and the top die when the press was operated. Employees then turned on the press and actuated the foot pedal until the top die piston was fully actuated. If the dies looked as if they were going to touch, employees took their foot off the pedal and backed the lower die down further. Once confident the dies wouldn't make contact, employees kept their foot on the pedal. Employees performed the die setup with the press on. In this incident, the employee loaded dies into the press and actuated it to verify proper die alignment. When the press was actuated, the upper and lower dies made contact, resulting in a die failure. A die disintegrated. Fragments of the die struck the employee's right hand and index finger. She suffered a laceration of the hand and a fracture of her index finger. In addition, fragments of metal were embedded in both her hands. She was transported to the hospital, where she received emergency care. She was hospitalized. There was no machine guarding in place, and energy control measures were not performed during die setup.

Keywords: Die, Disintegrated, Finger, Flying Object, Foot Control, Foot pedal, Fracture, Hand, Hydraulic Press, Laceration, Lockout, Lockout/Tagout, Machine Guarding, Machine operator, Press, Press Operator, Set Up, Shrapnel, Struck By