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Occupational Safety and Health Administration OSHA

Accident Report Detail

Accident: 200200194 - Crushed By Robot Arm During Machine Cycle

Accident: 200200194 -- Report ID: 0418200 -- Event Date: 01/27/1997
InspectionOpen DateSICEstablishment Name
30017269901/28/19973465Itt Automotive, Precision Die-Casting
An employee was operating a die-casting machine used to manufacture automotive parts. At the beginning of the first shift, each die pair has a Julian date screw installed with the current date on it. Operators from each of three shifts would punch a dot on the date screw to have the stamp indicate on which shift the parts were manufactured. One day, a backup die-casting machine operator was punching a dot for the second shift on the two pairs of dies on his machine. No one was watching him. While he was doing this, an alarm on the machine sounded. This alarm is designed to announce when there is a problem, such as the machine's jamming or operating out of sequence. Nearby machine operators heard the alarm and responded. When they approached the machine, they saw the backup die-casting machine operator in the die area. They found that his head was severely crushed. The machine was on. The robot arm had been stopped after it had removed the part and moved out of the way. The automatic sprayer had been turned off, but the machine was left on and in automatic. The machine had not been locked out. Investigation revealed that, with the robot arm off and out of the way and with the sprayer shut off, the machine will continue to cycle if not turned off. The employer had a lockout program that was inadequate. It did require employees to lock out the die-casting machines during repair or adjustments in the die area. However, employee interviews revealed that it was routine for the die punching operation to be performed without the machine being locked out. In addition, two supervisors admitted that they did not enforce the requirement to lock out the machines. In fact, they had worked in the die areas themselves without locking out the machine. The machine runs automatically, without human intervention, as long as there are no problems or adjustments to be made. The injured operator was not permanently assigned as a die-casting machine operator and may not have been as familiar with the machine's operation as he should have been. Because the injured employee had disabled the robot arm and the automatic oil sprayer but did not disable the machine itself, the machine was still in the automatic mode and ready to cycle. The operator had enough time to enter the die area and to start to punch the date screw before the machine started to cycle. The machine cycled while he was in the die area. A door closed off the die area before the machine activated, and the door closed and trapped the employee in the die area.
Keywords: head, robot, work rules, lockout, crushed, point of operation
Employee # Inspection Age Sex Degree Nature Occupation
1 300172699 Fatality Other Punching and stamping press machine operators

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