Inspection Detail

Inspection: 309977452 - Quaker Manufacturing Corp.

Inspection Information - Office: Cleveland Area Office

Investigation Summary

At approximately 7:00 a.m. on September 26, 2006, Employee #1 was operating a part revolution mechanical power press (Rousselle 10 ton). The press had brake monitoring and control reliability and was actuated and guarded through the use of two hand controls. The brake monitor was operating properly and was tripping on a regular basis. The keys to the mode selector of the press was left in the controls and allowed die setters, maintenance workers, and operators access to the mode operations of the press. When the press brake monitor tripped, which indicated a problem with the press, the standard procedure for operators would be to place the press in inch mode and cycle the press back to the top of the stroke. The operator would then cycle the press a couple of times and continue running the press. During press operation, Employee #1 cycled the press and reached into the point of operation to remove a part. When the press cycled, his hand was crushed. He was hospitalized for multiple wrist fractures and a hand puncture. The press' clutch and friction plates were severely worn and one of the clutch plates had broken apart, allowing one-third of the plate to rotate and slide next to the remaining two-thirds, closing the gap between the clutch plate and the friction plates. The broken pieces of the clutch plate caused the clutch to override the brake and started the press cycling in a continuous mode without any activation of the press controls. The employers press inspection program had not been properly maintained. The last record of maintenance on the press was 21 months prior to this incident. No reports, inspections, or maintenance activities were done in response to the tripping of the brake monitor.

Keywords: FRACTURE, HAND CONTROL, INADEQUATE MAINT, POWER PRESS, INTERLOCK, TWO-HAND CONTROL, CRUSHED, HAND, PRESS, WRIST