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Occupational Safety and Health Administration OSHA

Accident Report Detail

Accident: 102106.015 - Sheet Shear Operator'S Fingertip Is Amputated During Setup

Accident: 102106.015 -- Report ID: 0521400 -- Event Date: 01/02/2018
InspectionOpen DateSICEstablishment Name
1286978.01501/10/2018Ex-Tech Plastics, Inc.
At approximately 8:45a.m. on Jan 2,2018, a 50-year-old male was working as a mac hine operator for a manufacturer of plastics products. He was a full-time, regul ar employee and worked for the firm almost 20 years. He was working on the first shift in the extrusion department. He and a coworker were setting up a portable plastic sheet shear on Extrusion Line Number 1.It was normal for two operators to assist each other during setup.The shear was plugged in to an electrical ener gy source and turned on, but not running.A slowly moving continuous plastic shee t was coming from Extruder Number 1.It had to be guided toward and through the p ull rollers on the shear. Initially, both workers were standing between the extr uder and the shear.The coworker cut the sheet with a knife and folded one end at an angle.The employee walked away from the sheet to the other side of the shear to receive the sheet.He stated that he did not walk by the side of the shear wi th the operator's control station and that he did not press the controls to init iate any functions, such as activating the cutter or opening the pull rollers. H e stated that the pull rollers were already vertically a few inches (several mil limeters)apart. This opening was necessary for the coworker to feed the folded p oint of the material into the shear.The employee was standing in a forward-leani ng, slightly bent position, with his arms extended toward the point of operation .He held a small brass scraper in his right hand to guide the sheet through the shear.His left hand was positioned to receive the sheet once he had pulled it th rough the rollers with his right hand.His right hand was immediately next to the point of operation.As he guided the sheet through the shear's cutter area, the tip of the index finger on his right hand was in the point of operation, directl y under the unguarded cutting blade.The horizontal cutter blade unexpectedly cyc led, moving down against its lower permanent fixture and back up.Immediately, th e employee sustained a complete distal phalanx amputation of the fingertip.He ye lled to his coworker that his finger was cut.He folded his right hand into an up right fist, with his left hand covering it.After the coworker told the employee to seek first aid from CPR-trained personnel and stopped the machinery, the empl oyee walked away from it.Other coworkers called emergency medical responders.The employee was taken by ambulance to a local hospital emergency room.He was not h ospitalized.The cause of the unexpected startup was unknown. A system malfunctio n or failure, such as a short circuit, could have occurred, sending an erroneous signal.It was also possible that the employee or coworker initiated a function at the operator's control panel, causing the activation.Pressing the red open bu tton would have caused the pull rollers to open.This step would have caused the counter roller, in direct contact with the top pull roller, to turn.An input sig nal sent from the counter roller, measuring the progress of the plastic, would h ave initiated the cutting cycle, as if the required length of sheet had been fed through the shear, and that the sheet was ready to be cut.Other possibilities i ncluded a malfunction or failure, or the operator's intentional pressing of the function controls at the control panel to carry out setup tasks.Management repre sentatives claimed that no deficiencies were found in a post-incident inspection that would have resulted in an unexpected, unintended, or uninitiated cycle act ivation.Although there was no need for the shear to be energized during the feed ing part of the setup, machine operators were not required to deenergize the she ar by disconnecting its cord and plug.The employer did not recognize machine ope rators as authorized employees under the company's lockout program, but it did r equire them to perform servicing tasks of limited scope, such as setup, without deenergizing the machine.
Keywords: amputated, amputation, die, die blades, emergency response, equipment operator, finger, lockout, lockout/tagout, machine guarding, nip point, set up, shear
Employee # Inspection Age Sex Degree Nature Occupation
1 1286978.015 50 M Non Hospitalized injury Machine operators, not specified

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