Inspection Detail

Inspection: 310569975 - Ford Motor Co., Casting Plant

Inspection Information - Office: Cleveland Area Office

Investigation Summary

At approximately 5:00 p.m. on February 2, 2007, Employee #1, a relief operator in the Truck Modular Engine area of the Cleveland Casting Plant, had just relieved the regular cell operator of the #5KT machine for his 30-minute break. The #5KT machine combines casting core assemblies into a single core package, and has two tubs mounted on each end of a rotating table/carousel. While one end is being cured the other is in position to have manipulators from the right and left sides load the core assemblies. The table turns 180 degrees and indexes back to zero during the process. The table makes a complete 180 degree turn in approximately 4 seconds from start to finish. The rear of the machine is enclosed with interlocked access doors and the sides have fixed barrier guards installed. The front of the machine has the operator's control stations and has a guardrail barrier in place to prevent inadvertent access into the machine's danger zone. The two control panels have mode selector switches for the left and right manipulators and the #5KT machine. The right manipulator and the machine mode selector switches are located very close to each other and are identical. The guardrail slides into two sleeves mounted to the floor and can be easily lifted and moved to the side to allow employee access to the cell. The guardrail was not secured or interlocked with the core-making equipment. The rotating table has a drift pin that is to be put in place by the operator prior to entering the cell area. When the pin is in place, it activates a switch that prevents the table from turning. If the switch were to fail, the pin is of sufficient size that the table would not be able to turn. The floor is uneven and has several steps and floor grates inside the machine cell area. The floor of the machine area is covered with sand from the core manufacturing process. Employee #1 was wearing safety boots and work coveralls at the time of the incident. A quality control employee was in the area and noticed the #5KT line was not running and proceeded to the machine to determine why. Apparently, Employee #1 had placed the right loading manipulator into the manual mode, but did not place the #5KT machine in manual mode. Also, the drift pin was not placed into the rotating table as per normal operating procedures. He removed the front access guardrail and entered the machine. He was within the machine's rotating table arc when the table automatically indexed, striking him and hitting him against the machine frame at a point where there is approximately 2 inches of clearance between the machine frame and the rotating table. He was killed, and was found lying face down within the east end of the machine enclosure.

Keywords: WORK RULES, CASTING, MACHINE OPERATOR, CAUGHT BY, INTERLOCK, LOCKOUT, CRUSHED, MACHINE--MISC