Inspection Detail

Inspection: 309303758 - O K International

Inspection Information - Office: Santa Ana District Office

Investigation Summary

On October 1, 2008, Employee #1 was working as a maintenance worker. A coworker was operating an "Automatic Dasher Machine" with Asset Tag Number 2857. This was a custom designed machine used for affixing an aluminum foil seal onto a small circular plastic part. These perforated disc-type plastic parts, with a 1.5-in. diameter, were automatically fed, one part at a time, from a hopper with a chute leading into the point of operation where a strip of aluminum foil is also fed from a spool. The machine automatically aligned plastic discs, one at a time, onto the aluminum foil and a punch press type ram pressed the plastic part and the aluminum foil together to affix the foil diaphragm onto the disc. Then, the completed parts fell automatically onto a moving conveyor belt, which dropped them into a bin. For the normal operation, the process would be completely automated, and the point of operation would be properly enclosed. At the time of this accident, the coworker was operating this machine. Due to a part misalignment, a plastic part got stuck in the top part of the punch die and jammed the machine. This part of the die was attached to the up and down moving ram, and consisted of a smaller cylinder sliding vertically inside a larger cylinder. The plastic part was stuck in the gap between these two cylinders. The coworker asked Employee #1 to unjam the machine. Employee #1 turned the electrical power off and disconnected an air hose to cut off the pneumatic power to the machine. Then Employee #1 tried to pull out the stuck part with his hand when a piece of the plastic part broke inside the two sliding parts of the top die. Employee #1 tried to pull out the broken piece out of the top die with his right middle finger. When the broken piece was dislodged, the inner cylinder moved and pulled Employee #1's finger into the gap between the two cylindrical parts of the die. This inadvertent movement occurred due to the residual air pressure in the mechanism. Employee #1 suffered the amputation of his right middle fingertip, which included the loss of entire nail and some bone. Employee #1 was treated in the emergency room and was not hospitalized overnight.

Keywords: DIE, AMPUTATED, FINGER, JAMMED, RAM