California Department of Health Services
A summary
of this document is available in english and spanish.
(Un resumen de este documento está disponible en inglés y español.)
SUMMARY: CASE
193-209-01
Early
one morning a worker was setting up her work station in a
packing plant. Her job was to stamp fruit boxes as they moved
past her on a roller transport system. First she had to put
a hair net on and arrange the stamps on her table. Her table
was right next to the roller transport system. As she laid
the stamps on the table, one fell on the ground.
The
worker began bending over to pick up the stamp. Her hair net
was not on yet. Her long, loose hair grazed the fast moving
rollers and started tangling in them. The rollers continued
pulling her hair in until a large part of her scalp tore off.
Immediately,
her supervisor turned off the rollers and wrapped the injured
worker's head in a shirt. Co- workers ran to the plant office
to call 911. Later, at a hospital doctors tried, but could
not reattach the worker's scalp.
How
could this injury have been prevented?
- Employers
should require workers to put on all personal protective
equipment before entering the work area (such as hair nets).
- Employers
should make sure work areas are free of hazards (such as
unguarded rollers).
- Employers
should install the safest possible equipment in the work
area.
- First
aid kits should be in the work area.
BACKGROUND
On June
23, 1993, NURSE staff identified an injury in a packing plant
while reviewing records at a Regional Trauma Center. On June
16, 1993, a packing line worker lost 40% of her scalp while
setting up her work station area. Her hair became tangled
in a roller conveyor system when she bent over to pick up
a stamp off the floor.
On July
14, 1993, a nurse from the NURSE Project interviewed the injured
worker by telephone. On September 10, 1993, the nurse and
a safety engineer conducted an on-site investigation. They
also discussed the incident with the plant co-owner and a
supervisor who was in the plant during the incident. NURSE
staff also reviewed the California Occupational Safety and
Health Administration (Cal/OSHA) "Accident Report," the ambulance
patient run sheet, and hospital medical records.
The
plant co-owner notified Cal/OSHA on June 17, 1993. At the
time of this NURSE Report, the Cal/OSHA investigation report
was not available.
During
the on-site investigation, the safety engineer reviewed the
employer's written injury and illness prevention program and
noted it addressed all points as required by Title 8 California
Code of Regulations 3203 - - Injury and Illness Prevention
Program. (As of July 1, 1991 the State of California requires
all employers to have a written seven point injury prevention
program: 1. designated safety person responsible for implementing
the program; 2. mode for ensuring employee compliance; 3.
hazard communication; 4. hazard evaluation through periodic
inspections; 5. injury investigation procedures; 6. intervention
process for correcting hazards; and 7. provide safety training
and instruction.)
The
incident took place at a packing plant owned and operated
by two brothers. It employs 10 full-time workers (working
38+ weeks per year), 30-90 seasonal workers (working 13-37
weeks per year), and 6 family members. The injured packing
line worker was hired as a seasonal worker two and one half
months before the incident. She stated she had received verbal
and written safety training relating to her tasks.
INCIDENT
On June
16, 1993, at approximately 7:50 a.m., a 21 year- old Caucasian
female packing line worker was setting up her work station
table. Her job task consisted of stamping boxes with the type
and size of fruit as they moved past her on a chain driven
roller conveyor system. The rollers rotate rapidly to move
the boxes down the conveyor system (see Figure 1).
The
packing line worker laid the stamps on her work station table,
located next to the conveyor belt. One of them fell to the
ground. Because she had not yet started her job task, her
long hair was not in a hair net. As she bent over to pick
up the stamp, her hair became tangled in an unguarded section
of the rapidly moving roller conveyor system. Although she
tried, the packing line worker could not reach the emergency
turn off button approximately 10-12 inches from the roller.
The right front section of her scalp tore off.
A supervisor
heard the packing line worker screaming. He saw her standing
with her face and clothes covered in blood. He quickly shut
off power to the roller conveyor system. Certified in first
aid, the supervisor wrapped a shirt around her head to control
the bleeding. Then, he retrieved the scalp from the roller
conveyor system and placed it in a bag on top of ice. Concurrently,
co-workers ran into the plant office to call 911.
Emergency
Medical Services (EMS) received the call at 8:07 a.m., and
arrived on the scene at 8:13 a.m. They applied head pressure
dressings, administered oxygen, and started an IV. At 8:29
a.m., the injured packing line worker was transported to a
Regional Trauma Center. Arriving at 8:52 a.m., emergency department
staff cleaned her exposed skull bone and applied a clean,
sterile dressing. She was given pain control medication.
At 10:20
a.m., she was transported, by helicopter, to another medical
facility for microsurgery to reattach her scalp. She remained
hospitalized for seventeen days and then was released for
a holiday weekend. Upon readmission after the holiday, it
was apparent the attachment was unsuccessful. The scalp was
surgically removed. However, skin grafting surgery was performed
in which the top layer of skin was taken from another part
of her body and transplanted on her skull. She was released
July 13, 1993.
The
nurse and the safety engineer from the NURSE Project again
met with the injured packing line worker on September 1, 1993.
Although she stated she was recovering well and the graft
was successful, she did not expect to return to work for at
least a year.
PREVENTION STRATEGIES
- Employers
should require workers to put on all personal protective
equipment before entering the work area. In this incident,
the employer did require workers to wear hair nets. However,
the injured worker was setting up her work station, and
putting a hair net on was a part of that process. If she
had been trained to put on her hair net before entering
the work area, her hair may not have been loose and able
to tangle in the rapidly moving roller conveyor system.
The plant owners did implement this policy after the incident.*
Title 8 California Code of Regulations 3380(a): Personal
protective devices of the proper type and design shall be
provided to eliminate the hazard.
- Employers
should keep the work environment free from hazards. In this
incident, an unguarded area of the roller system caught
the injured worker's hair. Although the chain drive was
guarded, the moving rollers were not (see Figure 2). After
the incident, the owners placed a temporary cardboard guard
over the rollers not used to move smaller boxes. This covered
the unused moving rollers closest to the injured worker's
station while still allowing the system to function. A permanent
adjustable guard should be installed.* Title 8 California
Code of Regulations 4002(a): All machines, or parts of machines
which create hazards, shall be guarded.
- Employers
should consider safety when installing and upgrading equipment.
At the time of this incident, the employer was in the process
of replacing the entire conveyor system with a pressure
sensitive belt driven roller conveyor system. This type
of system is designed to stop moving as soon as there is
resistance in the rollers. An example of resistance is hair
entanglement. In this incident, the older style conveyor
system was still in place at the injured worker's work station.
If the plant would have installed the safer conveyor system,
this incident may not have occurred.
- Employers
should place first aid kits in easily accessible locations
in the work area. In this incident, although the supervisor
was certified in first aid, he did not have quick and easy
access to a first aid kit. It was in the plant office, which
is approximately 200 feet from the incident location. In
this incident, the supervisor responded quickly to stop
the bleeding by wrapping a shirt around the injured worker's
head. However, if the supervisor had quick and easy access
to the first aid kit, the injured worker's head could have
been wrapped in clean and sterile dressings instead of a
shirt.
FURTHER
INFORMATION
For further information concerning this incident or other agriculture-related injuries, please contact:
NURSE
Project
California Occupational Health Program
Berkeley office:
2151 Berkeley Way, Annex 11
Berkeley, California 94704
(510) 849-5150
Fresno office:
1111 Fulton Mall, Suite 212
Fresno, California 93721
(209) 233-1267
Salinas
office:
1000 South Main St., Suite 306
Salinas, California 93901
(408) 757-2892
Disclaimer
and Reproduction Information: Information in NASD does not
represent NIOSH policy. Information included in NASD appears
by permission of the author and/or copyright holder. More
NASD Review: 04/2002
This
document,
CDHS(OHB)-FI-94-005-31
,
was extracted from a series of the Nurses Using Rural Sentinal
Events (NURSE) project, conducted by the California Occupational
Health Program of the California Department of Health Services,
in conjunction with the National Institute for Occupational
Safety and Health. Publication date: January 1994.
The
NURSE (Nurses Using Rural Sentinel Events) project is conducted
by the California Occupational Health Program of the California
Department of Health Services, in conjunction with the National
Institute for Occupational Safety and Health. The program's
goal is to prevent occupational injuries associated with agriculture.
Injuries are reported by hospitals, emergency medical services,
clinics, medical examiners, and coroners. Selected cases are
followed up by conducting interviews of injured workers, co-workers,
employers, and others involved in the incident. An on-site
safety investigation is also conducted. These investigations
provide detailed information on the worker, the work environment,
and the potential risk factors resulting in the injury. Each
investigation concludes with specific recommendations designed
to prevent injuries, for the use of employers, workers, and
others concerned about health and safety in agriculture.
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