Case report: #23KY003
Issued by: Kentucky State Fatality Assessment and Control Evaluation Program
Date of report: March 3, 2025
A 52-year-old press operator had been employed for about seven years at a facility that fabricated motor vehicle brake system components. Primary production involved stamping and forming parts from steel rolls. On the day of the incident, the worker was setting up a hydraulic fineblanking press for use. When the press was operated, a metal balance pin fractured from the pressure. A fragment of the pin was ejected from the press and struck the worker in the neck, opening several major blood vessels. He bled to death beside the press. Although no one witnessed the incident, a security system camera captured video of the worker inserting a rag into the machine to bypass the press door’s interlock switch. The employer had implemented a written safety program and provided safety training that prohibited the bypassing or removal of safety features such as interlocks and guards. The employer also had in place a disciplinary system intended to ensure compliance with work rules. A technician who maintained the press involved in the incident reported that it was a mystery to him how the pin could have shattered. Management at the facility also was unable to explain exactly how the event occurred.
To prevent similar occurrences, employers should:
- Consider Prevention through Design to “design out” or minimize hazards and risk.
- Provide guards to help protect workers from the hazard of flying debris ejected from power presses.
- Ensure equipment safety features cannot be bypassed.
- Provide training and communication specific to machine operations.
