Inspection Detail

Inspection: 313645970 - Carlton Forge Works

Inspection Information - Office: Long Beach District Office

Investigation Summary

At 3:45 p.m. on July 27, 2012, an employee was working as a production helper for a firm in Paramount, CA. The firm was a hot forging company at which hydraulic drop hammers and forges were used. Their products were primarily made of titanium and used in aerospace. The incident occurred while the employee was forging an engine part for a jet engine. At the time of the incident, an 800-ton (7,120-kilonewton) hydraulic drop hammer was being used to forge a titanium part in a cylindrical die. The center of the part was to have a cylindrical hollow post driven into it. Because the post was almost all the way into the part, a piece of titanium pipe 6 inches (150 millimeters) in diameter was placed on top of it, so that the drop hammer could drive it all the way into the part. As the hammer hit the piece of pipe, the pipe went slightly sideways into the hole in the top of the post. This caused a piece of the pipe to shear off, fly through the air, and hit the employee. The pipe that shattered was a shop tool and not the one called for in the blueprints. The piece that sheared off was horseshoe-shaped, 6 inches wide, and 4 inches deep (150 millimeters wide and 150 millimeters deep). It hit the employee in such a way that it entered his chest through an incision about 4 inches (100 millimeters) wide below the rib cage and over the liver. The employee was transported to a hospital, where he died. The incident was reported at 4:00 p.m. by the company's safety manager. The Division responded immediately, arriving at 4:30 p.m. An opening conference was held, and permission was given to continue the inspection.

Keywords: CHEST, POWER PRESS, METAL SHOP, MACHINE OPERATOR, EQUIPMENT FAILURE, STRUCK BY, FLYING OBJECT, PUNCTURE