Inspection Detail

Inspection: 300777083 - P&E Inc

Inspection Information - Office: Long Beach District Office

Investigation Summary

At approximately 2:20 a.m. on May 1, 2001, Employee #1, an acting floor man, was informed of a problem related to clogged nozzles of an injection molding machine (700-Ton Cincinnati Milacron Plastic Molding Machine Model Number 700-165, Serial Number, 4007A25/8413). As Employee #1 and the operator walked to press Number 4, the operator explained the problem. Employee #1 made some adjustments on the control panel and ran some parts. At this time, the parts being produced were incomplete. Employee #1 then left and came back a few moments later with a sharp wire hanger and a torch. Employee #1 opened the safety gate that protects the employees from the point of operation and got into the mold area of the press Number 4. The operator stated that it is common practice for the floor man to get inside the mold area and unclog the nozzles (a total of 4 nozzles in the die) by poking them with a piece of sharp wire heated with a torch. Employee #1 had cleaned out two nozzles when the supervisor came to press Number 4 to help fix the problem. As the supervisor approached the press Number 4, he noticed that the injection unit was not backed away from the machine. He told Employee #1 "you did not move the injection unit back". Employee #1 said, "I forgot", and then he grabbed the safety gate and closed it. As soon as the gate was closed the press cycled before Employee #1 was clear. The supervisor tried to stop the cycle and open the mold but he was unsuccessful. Then he noticed that the press cycle mode was in single cycle mode instead of manual mode. He then switched to manual cycle mode and opened the die. Employee #1 fell to the ground. Employee #1 sustained massive head injuries that lead to his death. The paramedics pronounced Employee #1 dead at about 2:36 a.m. at the accident site.

Keywords: DIE, FRACTURE, HEAD, MOLDING MACHINE, CAUGHT BY, LOCKOUT, CRUSHED