Inspection Detail

Inspection: 906192.015 - Smedberg Machine Corporation

Inspection Information - Office: Chicago South Area Office

Investigation Summary

At 11:00 A.M. on April 25, 2013, Employee #1 was trying to program and make adjustments to a pressure valve prior to trying out a new press die cushion installation. The employee requested that the contracting company send a pipe fitter to repair a broken airline in the basement at Line 19. The contractor arrived at the scene and a 39 inch steel pipe that was lying on the floor behind the pillar had a dented nipple and the 1-inch pipe union below the Ross dump valve was cracked. The contractor arrived and reconnected the 39 inch pipe that was lying on the floor to the exhaust side of the Ross dump valve and also replaced the broken 1 inch pipe union that was located 18 inches above the floor. When the repairs were completed, air was introduced into the system and a pipe leak check was performed. No defects were found. Employee #1 was standing at the air entrance point of the press cushion assembly on Line 19 in the basement of the facility. The employee turned the ball valve that controls the air from the plant system to the "OFF" position. Employee #1 went back to his initial plans of doing some programming/adjustments to the pressure valve prior to the die tryout. As the employee pulled the red handle of the Ross dump valve to dump all pressure from the air tank, air pressure evacuated out of the exhaust port and loosened the thread at the top of the exhaust pipe. The exhaust pipe spun around and struck the Employee #1 on the head. The employee was transported to a local hospital, but later taken to closer facility to his home to complete his recovery. Employee #1 died on June 28, 2013, as a result of complications from the injuries he sustained on April 25, 2013.

Keywords: Air Line, Die, Head, Pipe, Pressure Release, Struck By, Valve