Inspection Detail

Inspection: 108422551 - English American Tailoring Company

Inspection Information - Office: Department Of Labor, Licensing, And Regulation Division Of Labor And Industry Maryland Occupational Safety And Health

Investigation Summary

On February 22, 1989, Employee #1, a trained employee with three years of experience, was operating an Acme Cleveland Corp. model l510-S laser cutting system to manufacture men's and women's custom tailored suits. The system consists of a pallet shuttle that moves pallets with fabric into a cutting area with an enclosed top, bottom, and two sides. Plexiglass shielding is located at the pallet entrance and exit, with a small square opening at the lower corner on each side. The pallet is removed for review after cutting and then passed on to another portion of the shuttle, where the pallet is lowered and returned to the beginning of the system. All movement is controlled by an operator via computer console. Daily test cuts are made prior to beginning work to detect problems, and weekly and monthly maintenance checks are also performed per the manufacturer's specifications. Documented major repairs are performed by an outside contractor. On the day of the accident, a test cut was performed and, because no problems were detected, Employee #1 inserted a pallet, initiated the first cut, and moved away to review documents in preparation for the next cut. When she returned to the control position, she noticed that no cuts had been made. She leaned forward, looked into the plexiglass, and reached up with her right hand to hit the halt button. She felt pain in her left forearm. Employee #1 had sustained second- and third-degree burns from a carbon dioxide laser beam. She was treated at a local hospital and released to return to work after scheduling follow-up visits. Subsequent investigation by the company found that a screw had become loose on one of five reflective mirrors that controlled the laser path direction. The resulting shift in the mirror allowed the beam to overshoot it and exit the cutting area. The manufacturer has built-in provisions for automatic shutdown of the laser due to overheating, but not for a misalignment of the beam path. A maintenance technician resecured the mirror, checked all other mirrors, and applied Locktite to all screws to prevent a reoccurrence of this incident. The same was done for the employer's two other systems, which are identical to the unit involved in this accident.

Keywords: BURN, INADEQUATE MAINT, LASER, CARBON DIOXIDE, ARM