Inspection Detail

Inspection: 307339044 - Dobake Bakeries, Inc

Inspection Information - Office: Oakland District Office

Investigation Summary

At approximately 5:00 a.m. on June 24, 2005, an employee was changing the blade, called a guillotine, on a pastry dough slicing machine. The changing the blade required the Plexiglas guard protecting workers from the blade to be open. On the Monday prior to the incident the machine he was working on stopped running because of a malfunctioning sensor on one of the guards. The sensors were designed to stop the machine if one of the guards was opened. A maintenance mechanic electronically bypassed the interlock mechanisms for all the guards. This allowed the machine to run with the guards open and hazardous parts exposed. The condition existed for five days. When the employee began the task of changing the blade, his supervisor instructed another coworker to turn off the power to the conveyor. The power source was located in an area where the conveyor was not visible. The power source was not locked, nor was accident prevention tags or signs placed on the controls. As the employee was completing installation of the guillotine assembly, the supervisor was standing approximately 20-ft away not looking in the direction of the employee. Neither the supervisor nor the coworker at the control panel could see that the employee still had his hand under the guillotine. The supervisor instructed the coworker at the controls to start the machine. The guillotine activated and started its downward stroke striking the employee's fingers and causing the lacerations. The employee incurred lacerations to the third, fourth and fifth fingers, including laceration of the flexor tendon, third finger, all on his right hand. His injuries did not result in hospitalization.

Keywords: SLICER, FINGER, CAUGHT BY, LOCKOUT, LACERATION, UNGUARDED