Injury prevention

OSHA's most interesting cases

What happened – and lessons learned


OSHA's most interesting cases Page 3 of 4

Case #2: Lockout/tagout-related amputation

A 50-year-old sanitation worker lost part of his right middle finger while attempting to clean a dough machine.

The employee, working an overnight shift, had been employed by a snack foods manufacturer for about a year – including six months as a temporary worker. He had worked at this particular facility for six weeks.

At his previous location with the company, he would clean the dough machine after it was disassembled and taken to another room. On the night of the incident, he was attempting to clean the machine while it was still on the factory floor.

The employee was scraping off dough from a hopper when the machine turned on and cut off part of his finger.

Lord said the company didn’t train its sanitation employees on authorized lockout/tagout procedures, and didn’t give them locks or ensure locks were used.

“The employer only told the sanitation employee, ‘Make sure the machine is off,’” Lord said. “They never showed him how to do it. They never gave him a lock. This was true for all the cleaning that sanitation workers did in their overnight shifts.”

OSHA actions: The agency issued two serious, one willful and one repeat citation to the manufacturer, which had been cited multiple times in the past for lockout/tagout issues. One of those citations stemmed from another amputation, Lord noted. The initial fines totaled $206,019, but were later reduced to $152,934 by an administrative law judge. In addition, the citations were changed to three serious violations and one repeat violation.


Lord said the takeaways from this case are from the enhanced settlement agreement that OSHA entered into with the company. That agreement affected four locations in OSHA’s Region 2 (three in New Jersey and one in New York), but had a “trickle-down effect,” Lord said, to the company’s other facilities around the country.

Conduct safety audits. The agreement requires at least two safety audits, led by an outside consultant, each year. Those audits cover lockout/tagout, as well as machine guarding and forklift safety.

Implement a safety and health program. The company was required to implement a safety and health program based on OSHA guidelines and OSHA Publication 3071 (Job Hazard Analysis).

Hire personnel with authority to oversee safety. The company had to hire a full-time safety manager for each of its manufacturing facilities and a corporate safety director. Before the amputation, the company had a corporate safety and health manager who said he developed a lockout/tagout audit program. However, Lord said the manager “had no authority to enforce that the audits were done.” That was under the purview of a plant manager, “who had no idea about lockout/tagout.”

Train employees in a language they understand. All of the manufacturer’s employees in the four Region 2 locations, from those in the corporate offices to those working in the factories, had to undergo safety training. That included temporary employees and contractors. “So everyone knew what their responsibility was for health and safety,” Lord said. That training also was provided in different languages. The facility where the amputation occurred had employees who spoke primarily Spanish or Vietnamese.

Start a safety committee. The agreement required the company to develop a safety and health committee, consisting of management, employee and union representatives. The company had to give the committee resources, and the committee had to provide reports. “The settlement agreement was the takeaway here,” Lord said. “It helped ensure no one else would suffer this type of injury.”

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