Inspection Detail

Inspection: 311162325 - Boc Water Hydraulics, Inc.

Inspection Information - Office: Cleveland Area Office

Investigation Summary

At 1:30 p.m. on July 19, 2007, Employee #1 was killed when a CNC Machining Center being installed rolled on top of him. Employee #1 was hired as the company's Chief Engineer, and was in charge of the facility. Employee #1 was working with another employee installing the new Milltonics RW15 Machining Center that had arrived that morning. The machining center had been placed in the facility where it was going to be mounted, but was still mounted to the shipping pallet. Employee #1 made plans to lift the 6,500 lb. machining center by jacking up the back of the machine using an air bladder type of lifting device, a double convolute type air spring, Model Number YI-2B12, Assembly Number 419, rated to lift/support up to 8,200 lbs. He was then going to lift the front of the machining center with the company's forklift and pull the shipping pallet out. The air spring is used by the company as a component in a valve they manufacture, and is not designed or intended to be used as a fully supported jack. Employee #1, had experience utilizing lifting bladders as the assistant Fire Chief of a local volunteer fire department, and wanted to use them for this lift. Installation of the previous machining centers in the facility was contracted out. However, due to the smaller size of this machining center, Employee #1 told the company president they could position the machine and get it mounted to the floor themselves. The machining center mount base is 26.5 inches wide and the main body of the machining center is 73 inches wide, and overhangs the base on each end. The mounting base is positioned at the center of gravity on the machining center, creating a 23.75 inch overhand on the left side of the machining center. Employee #1 was positioned under the left side overhang on his hands and knees and placed the air bladder lifting device under the machining center inside the mounting base. The air bladder was connected to the shop air and controlled through a quarter-turn shut off valve in the air line. Employee #1 inflated the air spring until it contacted the milling machine and stopped. A second employee was positioned at the right end of the machining center. Employee #1 stated he wanted to see if the spring would lift the machining center and was going to inflate it a small amount before positioning the forklift. Employee #1 opened the valve and the machining center rose up suddenly and started to slowly roll to the left. The second employee grabbed the machine on the right side and tried to hold it down to prevent if from rolling over and yelled for Employee #1 to get out of the way. The machining center continued to roll causing the overhanging edge to strike Employee #1 in the back, pinning him to the floor in a fetal position face down. The machining center continued to roll until the upper edge of the machine struck an adjacent machining center and stopped. The second employee ran around the machine and noted that Employee #1 was pinned and yelled for a third employee who was operating a CNC lathe approximately 12 feet away. Other employees from the adjacent room also heard the yelling and responded to the scene. In an effort to roll the machine off of Employee #1, they hooked up the forklift with a cargo strap to the top of the machining center and attempted to pull the machine back into an upright position. The machine kept trying to roll back and they realized the air to the air spring was in the full open position, allowing the air spring to continue to push the machining center over. The second employee ran around to the back of the machine and disconnected the air spring from the shop air at the wall. They were then able to roll the machine back onto the pallet. At this time medical emergency responders arrived on scene and pronounced Employee #1 dead at the scene.

Keywords: AIR SPRING, ASPHYXIATED, ROLL-OVER, MILLING MACHINE, CRUSHED, INDUSTRIAL TRUCK, PALLET