Inspection Detail

Inspection: 1491015.015 - Woodward, Inc.

Inspection Information - Office: Denver Area Office

Investigation Summary

At 1:30 p.m. on September 1, 2020, an employee was working as a machine operator for a firm that made aerospace and industrial equipment. He was operating an EPG pneumatic bearing press on the firm's operations floor. This was not his usual workstation. He had been trained on this machine, but he was not aware that an unauthorized modification made to it to address operational issues had created a hazard. Before the modification, tooling would turn in during stator spacer pressing, a routine job. The modification prevented the tooling from turning in. During the machine's modification, a torque restraint bar blocking plate had been attached to the machine's ram cylinder. The modification had created a crushed-by hazard and amputation hazard for employees. When the ram cylinder raised after being activated by the machine's two-hand controls, a pinch point was created. This pinch point was not fully guarded during the machine's entire operating cycle, particularly during the upswing of the ram cylinder. All the firm's machine operators were required to know how to operate at least two different types of machines to be fully qualified for their jobs. A machine operator who was more familiar with this press was absent on the day of incident, and the employee, unaware of the pinch point, was taking his place. The employee pressed and released the two-hand activation buttons and then turned to speak with a coworker. There was a pause between cycles, and in that time, the employee inadvertently put his hand above the torque restraint bar blocking plate, the attachment added during the modification. When the pneumatic operating system released the ram cylinder, the cylinder rose. The tips of the index and middle fingers on the employee's right hand were crushed between the torque restraint bar blocking plate and the base of the ram cylinder. The extent of the injuries necessitated the surgical partial amputation of the two fingers. The employee was hospitalized.

Keywords: Amputated, Amputation, Caught Between, Caught By, Caught In, Crushed, Machine operator, Modified, Partial Amputation, Pinch Point, Pinched, Pneumatic, Pneumatic press, Power Press, Press, Surgical Amputation, Unguarded