Fatal accident on a cup filling and closing machine
Category : Allgemein
During the night shift, a malfunction occurred on the gripper head of the cup filler; due to this malfunction, the filled flan cups were not set straight into the cardboard trays. The machine operator informed a fitter from the fitter´s shop. The fitter opened a lateral protective cover of the machine in order to find the cause of the malfunction. He bridged the position switch of the protective cover with a counter-piece. Having restarted the machine, he performed adjustment and lubrication works. The machine now ran trouble-free. The fitter went back to the shop; however, he left his tool trolley at the machine as he expected another malfunction. The protective cover remained open with the position switch being bridged.
Shortly after, the fitter and a master fitter returned to the machine. They observed the machine together. When they thought having found the cause of the malfunction, the fitter fetched the tools required for the repair from his tool trolley. Returning, he found the master fitter bent into the machine; the protective cover was open. The master fitter´s head had got stuck in the machine, and was crushed by the gripper head against the frame of the machine casing. It was not possible to clarify whether the machine was running (cyclic operation) or inadvertently switched on at the operating panel on the opposite side while the master fitter was bending into the danger area. After this accident, six employees who had been present at the time of the accident suffered a post-traumatic stress disorder.
In order to allow fault clearance with the machine running, the position switch had been bridged; thus, access to the hazard point was possible.
Where work has to be done with the guards open, e.g. for fault finding and clearance, it is necessary to take appropriate measures such as inching mode with acknowledgment switch.