Inspection Detail

Inspection: 307896100 - Plastic Forming Company, Inc.

Inspection Information - Office: Cleveland Area Office

Investigation Summary

At approximately 8:00 p.m. on June 23, 2004, Employee #1, a 45-year-old male who had worked as a production supervisor for a plastics company since March 23, 2004, was relieving his blow mold machine operators for scheduled breaks. Employee #1 relieved the operator for Blow Mold Machine Number 4, who had worked as an operator for more than two years, and took over the operation to produce pieces. The operator took his break and returned to relieve Employee #1 at the operator's work station. Employee #1 did not relay any information to the machine operator during the change over. The machine operator stated that he believed Employee #1 had gone to give either the Number 3 or Number 2 Blow Mold operator a break. Employee #1 next went to the catwalk area to adjust the flow rate on Blow Mold Machine Number 4. The blow mold machine flow rate was adjusted each time there was a job change or a problem with the molds not filling completely. This process was completed by the production supervisors, only when the machine was operating. The production supervisor did not inform the operator when adjustments were being made. Employee #1 had to make adjustments at four points on the lower part of the die head, using a metal, Allen wrench tool, approximately 6 inches to 7 inches in length. The die head adjustment points were located at the 12, 9, 6, and 3 o-clock positions on the round die head. Four uncovered electrical connectors were located in the front section of the die head, and ten apparently uncovered connectors were located on the front side of the die head, facing the catwalk. There was no railing around the area where adjustments on either side of the catwalk were made and employees would have to lean to adjust flow. During the adjustment, Employee #1 may have either slipped or fallen, while leaning over to make an adjustment using his left hand, and he may have attempted to regain his balance. Employee #1 may have contacted the open electrical connects on the die head and may have been shocked. He then fell forward and struck the steel, 0.5-inch plate on the other side of the catwalk section. Employee #1 finally came to rest on top of the radiant heaters, 81 inches below the catwalk. While finishing his first piece upon his return from break, the machine operator heard a popping sound in the area. He paused, looked up and around the area from his station, and decided the sound must have been the machine making its regular-type noises. The machine operator continued operating the machine and finished his second piece. While the machine operator was lowering the mold, Employee #1's body came over the top and rested on the mold and emergency stop area. The machine operator stated that he believed Employee #1 was playing a joke on him. However, after he heard Employee #1's labored breathing, he knew Employee #1 was seriously hurt. The machine operator immediately ran over to Blow Mold Machine Number 3 and told the operator that Employee #1 had been seriously injured. The operator of Blow Mold Machine Number 3 did not believe the other operator because he often jokes at the shop. The machine operator went over to the e-stop and shut the machine down. He again told the operator of Blow Mold Machine Number 3 that he was not playing. At this point, one of the machine operators ran to the office area and summoned emergency medical services. Employee #1 was transported to Doctors Hospital in Massillon, Ohio, where he was pronounced dead. Employee #1 sustained first to second degree burns on his body, after he fell on the radiant heaters. Preliminary tests showed electrocution as the cause of death. The employer reported the accident on June 24, 2004, more than eight hours after Employee #1 was killed.

Keywords: RAIL, MOLDING MACHINE, ELECTROCUTED, CATWALK, ELECTRIC SHOCK, FALL, FALL PROTECTION, UNGUARDED, UNSTABLE POSITION