Inspection Detail

Inspection: 309186674 - Inca Presswood-Pallets, Ltd.

Inspection Information - Office: Columbus Area Office

Investigation Summary

At approximately 2:00 p.m. on September 25, 2006, Employee #1 was part of a crew of four employees that was performing maintenance on a Dieffenbacher hydraulic compression press. The upper press die ram was supported by two square metal tubes (each approximately 2 in. by 48 in. by 0.375 in.) between the top block and the ram piston cylinder. These supports remained in place for approximately six weeks while the press was not operational. There were no die blocks in use. All employees from the crew stated they were between the elevated die and lower die bolting or performing other maintenance activities at various times. Energy sources on the press (electrical, hydraulic, kinetic, steam, and pneumatic) were not isolated and locked out. While Employee #1 was between the dies cleaning the die stops, he was crushed by the dies and killed. According to the company's accident investigation report, hydraulic fluid leaked from the press, increasing the pressure on the tube supports, and causing them to collapse and release the upper die ram onto Employee #1.

Keywords: LEAK, DIE, MAINTENANCE, PISTON, EQUIPMENT FAILURE, LOCKOUT, CAUGHT BETWEEN, CRUSHED, HYDRAULIC PRESS, PRESS