Inspection Detail

Inspection: 1568359.015 - Borghi Usa Inc. Oilhydraulic Conduits

Inspection Information - Office: Iowa 0751910

Investigation Summary

At 10:40 p.m. on December 5, 2021, an employee (new temporary hire) was working third shift from operating a hydraulic #6 Transfluid Model UMR 628 Flaring/Shaping Machine on a flare line. The machine capacity is 6 to 28 millimeters (mm) at 600 revolutions per minute (rpm), cycles every 4 to 10 seconds at 200 to 250 bar. Coworker #1 trained the employee, but he had been at the facility only 8 months and had never trained new operators. He did not inform the employee of the potential machine or work area hazards, did not review the operator manual or procedures, and did not inform the employee how to use operating controls including the emergency stop. The coworker also did not identify all hazard zones and nor discuss machine guarding or lockout/tagout (LOTO). No supervisor was present and Coworker #2 (Supervisor from another line) appeared briefly and left. The employee was trained how to put the sleeve part on the tube and place it on the die using his hand to keep it in place and then remove his hand before the die comes down. The employee learned by watching Coworker #1 a few times, and by performing the task multiple times. When Coworker #1 allowed the employee to operate the machine, he turned away as the employee attempted to slide the operator foot pedal to a more convenient position with his foot while holding the part in place. In doing so, he activated the machine and closed the die on his right index finger. The employee had been at work 40 minutes and was training for 15 minutes at the time. Machine guarding was insufficient to prevent machine operators from accessing the hazard zone and special tools for positioning of work materials were not used or available. The employee cried out and Coworker #1 tried operating the emergency stop, but the machine had already completely cycled. Coworker #2 transported the employee to the emergency room, where his finger was surgically amputated at the second knuckle. He was released the same day.

Keywords: Amputated, Amputation, Caught In, Crushed, Die, Distracted, Engineering Controls, Finger, Hand, Inexperience, Knuckle, Lack of Engineering Controls, Lack of Work Procedures, Machine Guarding, Machine operator, Material Handling, Misjudgment, Misjudgment of Hazardous Situation, Multi-employer Worksite, Multiemployer, Partial Amputation, Pinched, Point Of Operation, Staffing Agency, Temporary Employment Agency, Temporary Worker, Training