Inspection Detail

Inspection: 1785853.015 - Perma-Patch, Llc

Inspection Information - Office: Iowa 0751910

Investigation Summary

At 9:56 a.m. on October 31, 2024, an employee was working as a packaging machine operator for an asphalt and block manufacturer. The asphalt was located outside where it was raining, so the production line was not operating at the time. The employee and a coworker were putting three 60-pound perma-patch asphalt bags back through the line to be restitched and reflattened. The bags were filled the prior day but had been set aside due to defects in the stitching process. The bags had been closed with a Hamer Fischbein Model 400TNS NSR13BVDN34X14049 Sewing Head (serial Number 212876). The team had restitched and reflattened one bag and the employee stacked it on a pallet at the end of the line. The coworker sent the second bag through the sewing head, it was restitched, and began working on removing the defective stitching from the third bag. The flattener is a machine consisting of upper and lower belt conveyors inverted to each other and used to compress or flatten the bagged product. This flattener was set to a height of approximately 3 inches. While the coworker was occupied, the employee became caught in and crushed by the flattener. An emergency stop cable was located above the machine, but was not triggered. The employee entered the flattener to approximately waist level prior to the machine being stopped by the coworker using the emergency stop cable at the hopper/bagger/scale workstation. The second bag of asphalt was in the flattener near the end of the line and was broken or ripped open. The employee was located in the flattener just behind this second bag of asphalt. The employee's head and chest were crushed to approximately 3 inches, killing him.

Keywords: Asphalt, Back, Catch Point, Caught In, Chest, Contusion, Crushed, Face, Fracture, Head, Inexperience, Insufficient Supervision, Laceration, Lack of Work Procedures, Lockout, Lockout/Tagout, Machine Guarding, Machine operator, Material Handling, Misjudgment, Misjudgment of Hazardous Situation, Neck, PPE, PPE Hazard Assessment, Pinch Point, Pinched, Pulled In, Puncture, Puncture Wound, Safety Device, Shoulder, Unsafe Position, Work Surface, Wrong Equipment