Inspection Detail

Inspection: 301329082 - Great River Foods

Inspection Information - Office: Monrovia District Office

Investigation Summary

At approximately 11:30 a.m. on October 1, 2002, Employee #1 and a coworker were operating a fish separator which is designed to separate the fish meat from the skin and bones. He worked for Great River Foods for about two years, but had only worked on the fish separator for six or eight previous times. Employee #1 asked for a push stick but was not given one. His coworker had worked with Employee #1 for about two hours prior to the incident. His coworker said the tunnel guard was no where in sight but the roller safety guard was being used. The roller safety guard does not prevent entry into the point of operation. The roller safety guard formed a housing to which the tunnel guard should have been attached. A push stick could not be used without the tunnel guard. His coworker said he had seen the tunnel guard used only once during the three or four times he has helped out on the fish separator. Another coworker reported he always used the tunnel guard. Employee #1 said he had never seen anyone including the other coworker use the tunnel guard. When first interviewed, Employee #1's supervisor said he did not see the tunnel guard and that he told the other employees that the fish separator was a dangerous machine and encouraged them to put the roller safety guard back on. The supervisor said Employee #1 complied and put the roller safety guard back on. The supervisor said the tunnel guard was never used and he did not realize the tunnel guard was necessary. He always insisted the roller safety guard, sometimes called a flange guard, be used. Later, the supervisor said that employees always used the tunnel guard in addition to the roller safety guard. At the time of the incident, Employee #1 had removed the roller safety guard and was in the process of unjamming a fish. Employee #1 said he did not stop, de-energized, or disconnect the power source for the fish separator prior to attempting to clear the jammed fish. Employee #1 grabbed the jammed fish and attempted to push it through the separator. As he pushed, the glove on his right hand became caught between the rotating cylinder and the sleeve, pulling his hand into the separator amputating his right hand. His coworker turned off the fish separator. Employee #1 said that since the batch of fish was frozen, the machine would jam every five or six fish. Normally, the fish separator did not jam because the fish was not frozen. His coworker confirmed the fish was frozen, and the fish separator became jammed about every ten minutes. His coworker also said he had helped run the fish separator on three or four other occasions and had seen only one or two fish get jammed all day. But, on those occasions, the fish was not frozen. His coworker said that when he was working on the fish separator on those other occasions and the fish jammed, the operator always shut the fish separator off before attempting to unjam the fish. However, he had never seen anyone deenergize or disconnect the power source prior to unjamming. His coworker said that on the day of the incident, Employee #1 would sometimes shut off the fish separator and sometimes he would let the fish separator run while unjamming it. Employee #1 was transported to Saint Francis Medical center in Lynwood, California, where he remained for three days.

Keywords: AMPUTATED, CAUGHT BY, JAMMED, LOCKOUT, HAND TOOL, HAND