A millwright with more than 15 years experience was performing maintenance work on a press loader/unloader that transfers mats of wood chips and glue onto a conveyor. He was inside the press loader/unloader adjusting the tension of the tray belt when the machine cycled, pinning him between the tray and the press. He died as a result of his injuries.
Why did it happen?
A Ministry of Labour investigation found that the millwright had been told prior to starting the maintenance work that the press loader/unloader would cycle two more times before he could enter it. The machine was in automatic mode when the millwright entered it and it continued to cycle.
How can it be prevented?
The only safe way to conduct maintenance work on machinery of this kind is to ensure that all motion in the machinery had been stopped and blocked or, if all components cannot be blocked to prevent movement, to de-energize and lock out the control mechanisms.
This fatality is only the most recent illustration of the urgent need for much more vigilant training, monitoring and enforcement of lockout procedures to ensure that they are being implemented every time without fail. In order to be effective in preventing injuries and fatalities, lockout procedures need to be machine-specific. Workers whose safety might be jeopardized by mechanical movement need to know the specific steps that have been established to ensure their safety, and they need to know for sure that those steps have been taken.
Safety supply companies have created computer software with which a firm can develop graphical machine specific lockout procedures. But even the best lockout procedure-writing process won’t work if workers are not fully aware and trained in the importance of implementing lockout every time without fail, and if supervisors don’t monitor and enforce implementation of lockout as a key part of their daily responsibilities.
The main obstacles to effective lockout procedures are complacency, lapses in concentration and risk-taking. Tragedies such as this fatality show that when it comes to de-energizing and locking out potentially lethal machinery, there is no margin for error.