Inspection Detail

Inspection: 305476186 - Dynamic Cooking Systems Inc

Inspection Information - Office: Long Beach District Office

Investigation Summary

At 8:45 a.m. on June 4, 2004, Employee #1, a Set-Up Man/Press Brake Operator, and a coworker, were attempting to remove a section of the upper die of a press brake (manufactured by Amada, Model Number RG-80, Serial Number 804570). During the operation of this press brake, it's upper die would remain stationary and the bed and lower die traveled up to meet it. Neither employee had performed the die removal procedure together before with dies this size. The section of this die weighed 67 pounds and was 25.5 in. long. The unwritten procedure for removal of die sections this size was to raise the lower die up to the top die by pushing down on the control treadle. Once the set screws holding the section of upper die were loosened, one employee would lower the bed by allowing the treadle to rise while both employees steadied the top-heavy die section with their hands. When the bed had descended, one employee would lift the die section up and set it aside. At the time of the accident, the upper die section had been released from the upper die holder, and was resting on the lower die. The coworker was steadying the die section by holding its right side. Employee #1 was steadying the die by resting the fingers of his left hand on the top of the die section. Apparently, the coworker, when directed by Employee #1 to "lower it," lowered the treadle instead of lowering the bed by allowing the treadle to rise. When the bed raised back up, it crushed Employee #1's finger between the die section and the upper die holder. The tip of the finger was medically removed.

Keywords: DIE, MAINTENANCE, AMPUTATED, PRESS BRAKE, FINGER, WORK RULES, CONTROL LEVER, CAUGHT BETWEEN, CRUSHED, COMMUNICATION