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Mar 22, 2023

FACE Report: Machine operator fatally struck by safety block ejected from mechanical power press

Report number: 16NY064 Issued by: New York Fatality Assessment and Control

Report number: 16NY064Issued by: New York Fatality Assessment and Control Evaluation Program Date of report: Oct. 6, 2021

A worker at a manufacturing facility was fatally injured while operating a 200-ton mechanical press. The worker and another employee were making bus bars, a component of electrical devices, out of raw copper strips. The mechanical press frequently jammed, requiring the worker to place two safety blocks between the ram and bolster and reach into the press to unjam it. The worker would then remove the safety blocks and actuate the machine at a dual-button control panel mounted to a pedestal in front of the long side of the press. The workers had to unjam the press multiple times. The last time they removed the jam, the safety blocks were unintentionally left on the bolster bed. The worker, who was standing in front of the press by the pedestal controller, actuated the press. The two safety blocks were immediately ejected from the press. One struck the worker in the neck and chest, causing severe injuries. A 911 call was made, and another employee tried to help using basic first aid. Emergency responders arrived within minutes, but the worker died at the scene. Cause of death was listed as blunt force injuries to the neck.

To help prevent similar occurrences, employers should:

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