Case report: #52-49-2021
Issued by: Washington State Fatality Assessment and Control Evaluation Program
Date of incident: Feb. 9, 2018
A 39-year-old hay press operator died when he was struck by the machine’s steel guillotine blade. The operator worked at a plant that processed hay baled in the field into high-density bales for shipping. Near the end of the operator’s work shift, the plant supervisor asked him and two other employees to prepare the machine for scheduled maintenance. The shift supervisor was at the machine’s control panel, waiting for a signal from the operator to turn off the machine’s power. During normal operation, a conveyor moves hay into the main press, where a scale and guillotine are located. When the hay reaches the correct weight, the scale triggers the guillotine, which slices off a section of the hay to be compressed. The operator crawled into the hooded intake opening of the main press to push a bale through to clear the area. As he was lying on the scale, the guillotine activated and struck him, resulting in near decapitation. He was pronounced dead at the scene.
To prevent similar occurrences, employers should:
- Enforce and evaluate employee compliance with machine manufacturer’s lockout/tagout requirements when servicing machines and equipment.
- Enforce lockout/tagout training that emphasizes the severity of the hazard of entering energized machines that have lockout/tagout requirements.
- Implement, enforce and evaluate a hazard reporting and response system that can document employee deviations from lockout/tagout requirements as well as initiate corrective actions when they reoccur.
- Perform risk assessments with the machine manufacturer to understand or customize safety control system features.
