Inspection Detail

Inspection: 301275129 - Global Bakeries, Inc.

Inspection Information - Office: High Hazard Unit - South

Investigation Summary

At 10:50 p.m. on March 1, 2002, Employee #1, a general production worker, sustained a serious injury while operating the proofer box oven at Global Bakeries, Inc, in Pacoima, California. Employee #1 has been employed by Global Bakeries, Inc. for the last 15 months as a Production Worker. Employee #1 was instructed on how to use the proofer oven by his direct supervisor. A typical night shift only includes one operator to operate the proofer oven. Other job tasks include mixing dough and cleaning up dough from the machines. The proofer box consists of long conveyor belts enclosed in a heated chamber. There are eight belts total in this oven. The temperature in this chamber is between 85 to 100 degrees Fahrenheit. Pita bread is formed and fed down into the oven at one end. Employee #1 has authorization to adjust the "Slider bar" and he has been doing so on a regular basis. This slider bar's purpose is to adjust the direction of the pita bread as it enters and exits the oven chamber when it is ready for the heating process. It is manually adjusted approximately every 15 minutes after the pita bread has entered the oven. The time frame needed to make this adjustment is 5 to 10 seconds. Employee #1 knows when to adjust this slider bar based on the cooking time of pita bread in the proofer oven. At 10:50 p.m. on March 1, 2002, Employee #1 was adjusting the slider bar to change the direction of pita bread flow. To adjust the slider bar, Employee #1 set up a stepladder by the access door to the oven, scaled the ladder, and opened the chamber door. Employee #1 reached in approximately 12 inches and adjusted the slider bar, when his hand got stuck in the moving conveyor belts and the slider bar itself. He yelled immediately, and two nearby employees heard his scream. Employee #1 told them to shut down the machine, but they did not know how to shut it down. Employee #1 then yelled to them to get a supervisor. Employee #1 continued to have his hand jammed between the slider bar and the conveyor belt. The power-off button was located approximated 25-feet towards the hopper feeder area, south of Employee #1's position. A coworker, 15 minutes later, was able to shut down the machine. Employee #1 had never been trained on lock-out procedures. Employee #1 was taken to Providence Holy Cross Hospital in Mission Hills, California. Employee #1 underwent several operations to his forearm and hand and has had a cast on since. Employee #1 spent 8 days in the hospital and was released on February 7, 2002. Since Employee #1's accident, he has been in therapy and getting weekly treatments. Employee #1 was offered by Global Bakeries, Inc. to return back to work under modified duty.

Keywords: FRACTURE, OVEN, CAUGHT BY, LOCKOUT, CONVEYOR, ARM