Inspection Detail

Inspection: 301279956 - Desa International

Inspection Information - Office: High Hazard Unit - South

Investigation Summary

At 11:45 a.m. on July 31, 2004, Employee #1, a machine operator in the Fabricating Department at the DESA manufacturing facility in Santa Ana in California, was operating a 100-ton press brake machine Number 15, manufactured by "Mada", Model Number 1025E. Employee #1's shift started at 5 a.m. the day of the accident. Around 10 a.m., his supervisor had told him that machine Number 15 was fixed after not working all morning. The supervisor told Employee #1 to perform the die set-up. Employee #1 asked how long the piece would be run so he would be able to adjust the die. The foot pedals were 12 in. away from his foot at the time of the accident. He had a wrench in his right hand, while his left hand was under the die. Suddenly, the machine activated without Employee #1's foot on the foot pedal. The ram crushed Employee #1's two fingers down to the opening, which was of the size of the medal to be worked on. The ram stayed there for approximately one-half second. Employee #1's fingers were amputated, and he was hospitalized. No block-out or lockout procedures were performed to prevent the inadvertent movement during the die setup as this machine was energized.

Keywords: DIE, AMPUTATED, BRAKE, FINGER, FOOT CONTROL, MACHINE OPERATOR, LOCKOUT, CRUSHED, HAND, PRESS