Worker trapped in pinch point of machine during maintenance
Date of incident: August 2013
Notice of incident number: 2013165830168
Employer: Company providing dry cleaning equipment and maintenance
Incident summary
A dry cleaning equipment vendor was replacing the collar table cover of a single collar cuff press. In order to reach the rear spring hook and attach it to the cover, he inserted his upper body into the space between the collar table pad and the collar press head. He inadvertently activated a safety feature on the machine, which caused the various parts of the machine to return to the neutral position. The vendor's upper body was trapped between the collar table and the collar press head. After being freed, he was resuscitated and transported to hospital by ambulance.
Investigation conclusions
Cause
- Vendor became trapped in machine when safety feature was activated: The vendor placed his upper body in a pinch point in the single collar cuff press while attempting to attach a spring hook to a new collar table cover. He inadvertently activated either the right safety bar or the emergency stop button. This caused the machine to return to the neutral position, which leaves only a 2.5-centimetre (1-inch) gap between the collar press head and the collar table. The vendor's upper body was trapped until the store owner reset the machine and then pressed the left and right start buttons simultaneously to activate the machine, thereby releasing the vendor.
Underlying factors
- Failure to fully de-energize the machine: The vendor did not isolate all energy sources before starting to change the collar table cover. Although the steam was off, the electrical and pneumatic power sources were still on. When the vendor inadvertently activated a safety feature, the machine was energized and was able to return to the neutral position and trap him.
- Failure to follow manufacturer's instructions: The vendor did not follow the manufacturer's procedure for changing the collar press cover.
- Congested work area: The area around the machine was congested and cluttered, with a wall on one side of the machine and a metal bin on the other. This restricted the vendor's access to the rear spring hook of the collar table. Moving the metal bin aside would have provided the vendor access to the rear of the collar table.