Inspection Detail

Inspection: 312361686 - Earth Grains Bakery

Inspection Information - Office: Oakland District Office

Investigation Summary

At approximately 4:45 a.m., Employee #1, a stationary engineer, deenergized a LeMatic modular roll slicing machine (Serial Number 807886) and locked and tagged it out of service, prior to performing maintenance work on it at a bakery. Employee #1 removed the panel covering the chain drive and sprocket mechanism. He changed the belt, lubricated the machine, and performed other preventive maintenance on the machine. Employee #1 then removed the lockout/tagout devices on the machine and turned the machine on, without replacing the panel that covered the chain drive sprocket mechanism. Employee #1 kneeled down next to the LeMatic slicer machine to check the belt alignment. As he was checking the belt alignment with the machine running, his left index finger contacted the chain and sprocket mechanism. This mechanism removed Employee #1's left index finger, just past the upper end of his finger nail. Employee #1 approached his supervisor, who was the onsite assistant chief engineer and was standing approximately 30 feet away from the LeMatic Machine. Employee #1 was holding his left index finger wrapped in a paper towel and a red rag. The supervisor immediately contacted the plant safety manager and 911 Emergency Services. Employee #1 explained what happened to his supervisor, while he waited for the ambulance. Employee #1's left index finger tip was recovered from the accident scene, but it was later determined that the fingertip was too badly mutilated for surgical reattachment. Employee #1 was treated at Kaiser Hospital in Oakland, California and remained at the hospital for was less than 24 hours. Employee #1 had been employed for approximately five years, and he had received lockout/ tagout training from his employer. The employer had provided an equipment-specific energy-control procedure form for the LeMatic bun roll slicing machine that was involved in the accident. The accident occurred during manufacturing "down" time, which meant that production was not in progress when the preventative maintenance was being performed. During the inspection, Employee #1 provided a statement for the Division. His statement confirmed that the accident occurred as described above. The supervisor stated that there were no witnesses who directly observed the accident when it occurred. The employer provided their lockout/tagout policy for Division review. The Division determined that Employee #1's act of removing the lockout/tagout devices and reenergizing the LeMatic bun roll slicing machine before replacing the cover panel was not consistent with the employer's lockout/tagout policy. Therefore, the Division was not justified in taking further action concerning this matter.

Keywords: CHAIN, MAINTENANCE, AMPUTATED, FINGER, WORK RULES, LOCKOUT, CAUGHT BETWEEN, SPROCKET, NIP POINT