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Occupational Safety and Health Administration OSHA

Inspection Detail

Note: The following inspection has not been indicated as closed. Please be aware that the information shown may change, e.g. violations may be added or deleted. For open cases, in which a citation has been issued, the citation information may not be available for 5 days following receipt by the employer for Federal inspections or for 30 days following receipt by the employer for State inspections.

Inspection: 307399246 - Pre-Press International Dba Digital Pre-Press Int.

Inspection Information - Office: Ca San Francisco

Nr: 307399246Report ID: 0950611Open Date: 01/29/2008

Pre-Press International Dba Digital Pre-Press Int.
645 Mariposa Street
San Francisco, CA 94107
Union Status: NonUnion
SIC: 2752/Commercial Printing, Lithographic
NAICS: 323110/Commercial Lithographic Printing
Mailing: 645 Mariposa Street, San Francisco, CA 94107

Inspection Type:Accident
Scope:Partial Advanced Notice:N
Ownership:Private
Safety/Health:Safety Close Conference:07/25/2008
Planning Guide: Safety-Manufacturing Close Case:

Related Activity:TypeIDSafetyHealth
 Accident362193054    
 Accident362193070    

Violation Summary
Serious Willful Repeat Other Unclass Total
Initial Violations 7 7 14
Current Violations 7 7 14
Initial Penalty $79,425 $0 $0 $1,940 $0 $81,365
Current Penalty $61,177 $0 $0 $970 $0 $62,147
FTA Amount $0 $0 $0 $0 $0 $0

Violation Items
# ID Type Standard Issuance Abate Curr$ Init$ Fta$ Contest LastEvent
  1. 01001 Other 3203 B01 07/28/2008 08/30/2008 $0 $325 $0 08/22/2008 F - Formal Settlement
  2. 01002 Other 3203 B02 07/28/2008 08/30/2008 $325 $325 $0 08/22/2008 F - Formal Settlement
  3. 01003 Other 3314 H03 07/28/2008 08/30/2008 $0 $325 $0 08/22/2008 F - Formal Settlement
  4. 01004 Other 23400024 07/28/2008 08/30/2008 $0 $160 $0 08/22/2008 F - Formal Settlement
  5. 01005 Other 25000008 A 07/28/2008 08/30/2008 $160 $160 $0 08/22/2008 F - Formal Settlement
  6. 01006 Other 25000010 A 07/28/2008 08/30/2008 $0 $160 $0 08/22/2008 F - Formal Settlement
  7. 01007 Other 3314 G02 A 07/28/2008 08/30/2008 $485 $485 $0 08/22/2008 F - Formal Settlement
  8. 02001 Serious 3314 E 07/28/2008 07/31/2008 $585 $5,850 $0 08/22/2008 F - Formal Settlement
  9. 03001 Serious 3328 G 07/28/2008 08/10/2008 $5,850 $5,850 $0 08/22/2008 F - Formal Settlement
  10. 04001 Serious 4000 D 07/28/2008 08/10/2008 $292 $2,925 $0 08/22/2008 F - Formal Settlement
  11. 05001 Serious 3203 A07 07/28/2008 08/10/2008 $5,850 $16,200 $0 08/22/2008 F - Formal Settlement
  12. 06001 Serious 3314 D 07/28/2008 08/10/2008 $16,200 $16,200 $0 08/22/2008 F - Formal Settlement
  13. 07001 Serious 4000 C 07/28/2008 08/10/2008 $16,200 $16,200 $0 08/22/2008 F - Formal Settlement
  14. 08001 Serious 4436 07/28/2008 08/10/2008 $16,200 $16,200 $0 08/22/2008 F - Formal Settlement

Accident Investigation Summary
Summary Nr: 201184090Event: 01/29/2008Die Cuting Operator Killed In Platen Press Machine
On January 29, 2008, Employee #1 was working as a Die Cutting Operator for Pre-Press International, Inc., dba DPI, in San Francisco, CA. Employee #1 was assisting a coworker, operating a manually-fed job platen press, also known as the flatbed creasing and die cutting machine. The tag affixed on the front of the machine had the following information: Creasing and Cutting Machine, ML 14001400 by 1000 mm 18 per minute SN: 8080028, Yawa Printing Machinery Co., LTD The manually-fed creasing and die cutting machine was not equipped with modern safety systems (e.g., guards, devices, signaling) to protect the operators during die setting (removal and placing of dies) and normal operation of the machine. At Approximately 11:25 a.m., Employees #1 and the coworker had finished a job which involved a large size die, and were about to start a new one utilizing a smaller die (22 in. X 26.5 in.) The platen working surface is approximately 40 in. by 55 in. (1000mm by 1400mm). They were positioning the die on the stationary platen. The coworker, who was the main operator of the press, was standing on the right side of the machine while Employee #1 was standing on the left side of the machine. The coworker started to secure the die between the upper and lower clamps on the stationary platen from its top right hand corner using a special wrench. When she then noted that the moving platen had been activated and was about to close on them. The coworker managed to pull her (left) hand out of the press, and pushed down on the safety bar located on the top of the moving platen. However, the moving platen continued closing, trapping the upper left torso, and left shoulder and arm of the Employee #1. The Employer summoned Emergency Medical Services. It took the local Fire Department approximately twenty minutes to extricate Employee #1. Who was pronounced dead at the scene. The cause of death has not been ascertained as the Coroner's report was not available at the time of this report. However, the cause of the incident was failure to disconnect the machinery from its source of (electrical) power and to ensure that all parts of machinery stopped completely prior to placing the die. Other contributing factors were: 1) Failure to train the employees in the safe operation procedures for this machine; 2) Failure to provide guards or devices that would have prevented the machine from closing on employees; and 3) Failure to have the two sets of operators' controls interlocked.
Keywords: die blades, shearing machine, shoulder, die cutting press, power press, torso, lockout, crushed, arm, die casting machine
Inspection Degree Nature Occupation
1 307399246 Fatality Other Occupation not reported

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