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
292-009-01
At a
vegetable processing plant, a machine operator's foot was
amputated while walking down a trimming line. On the trimming
line the vegetables are cut to size, and the trimmings are
dumped into a trough that runs along the floor. Inside the
trough a metal auger turns like a screw, pushing the vegetable
matter out of the trimming area. The trough is covered with
heavy grates. Somehow, one of the grates covering the trough
was not in place and the machine operator stepped or slipped
into the turning auger, tearing off the left foot and ankle.
The machine operator is not certain how the injury happened,
and nobody was watching. Co-workers, and then the fire department,
arrived quickly, stopping the machine and applying a tourniquet.
The injured machine operator's foot was too badly mangled
for the hospital to surgically reattach it.
How
could this injury have been prevented?
- The
guard over the moving auger should not be easy to remove.
- The
auger can be made of a lighter, more flexible material than
metal, such as rubber or plastic, which will give way when
a person's hand or foot becomes trapped.
- Contact
switches can be connected to the grate so that if the grate
is raised the power to the auger will switch off.
- Running
water, rather than an auger, can be used to carry vegetable
matter down the trough.
BACKGROUND
On March
22, 1992, a local newspaper reported that a machine operator
had been injured the previous day in a vegetable processing
plant. She suffered a traumatic amputation of the left foot
above the ankle when her foot was caught in a turning auger.
A Nurse
from the NURSE project identified the case when reviewing
the newspaper and discussed the incident with the injured
worker on April 15, 1992. On May 29, 1992, a NURSE team consisting
of the Senior Safety Engineer, the Epidemiologist, and a Nurse
visited the site and investigated the incident. The team also
discussed the incident with the plant manager, who was the
safety director at the time of the incident, and a representative
of the employer's workers' compensation insurer. NURSE staff
also reviewed the emergency medical service records and the
Cal/OSHA report on the incident.
Cal/OSHA
was notified the day of the injury by the local fire department
who responded to a 911 call made by a co-worker. Cal/OSHA
contacted the employer that day and investigated the incident,
which included reviewing the employer's injury and illness
prevention program. The safety program was found to be in
compliance with 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: designated safety person
responsible for implementing the program; mode for ensuring
employee compliance; hazard communication; hazard evaluation
through periodic inspections; injury investigation procedures;
intervention process for correcting hazards; and a health
and safety program.)
Also,
six months prior to this incident, the plant manager had begun
an updated safety program with videotaped instruction for
employees. The injured worker said she had participated in
this program and had received safety training related to operating
a trim machine.
INCIDENT
On March
21, 1992, at approximately 7:50 a.m., a machine operator in
a vegetable processing plant had her left foot and ankle caught
and torn off by a turning auger. The worker was a 49 year
old Hispanic female, a seasonal employee of the company for
five years. She was employed as a trim machine operator, trimming
vegetables to a uniform size before processing and shipment.
She was on her second day of work in the current season.
The
incident occurred next to one of the trim lines in the plant.
The vegetables are trimmed to the proper size at the lines.
The excess vegetable matter from the trimming is washed down
into a U-shaped trough set in the plant floor. The trough
is 10 inches wide, 12 inches deep, and runs 75 feet across
the plant. Inside the trough a metal auger continuously turns
and pushes the vegetable matter to a section of the plant
where it is processed into cattle feed. Protective grates
are recessed in the floor and cover the trough and auger.
The grates are made of flat metal strips which rest on 4 inch-wide
lips on either side of the trough. The incident was unwitnessed.
The processing plant was about to begin its day shift when
the employee went walking down an unoperating aisle of a trimming
line. She had worked on this line the previous day, but had
been reassigned to a different line the day of the incident.
The injured machine operator did not remember the incident
clearly. Apparently, the protective grating over the trough
had been dislodged or became dislodged, and her foot went
into the trough and was caught in the rotating auger. The
section of grating that was not in place at the time of the
injury was one of the smaller sections, approximately 18 inches
long and weighing about 34 pounds.
According
to the plant manager, a maintenance man was nearby when the
incident occurred. The maintenance man immediately called
for help. Two co-workers arrived and helped the victim while
the first worker ran to shut off the power to the screw conveyor
system. The cut off switch was approximately 200 feet away.
Co- workers trained in first aid applied a tourniquet to the
left leg to control bleeding and called 911.
The
local fire department responded to the 911 call and arrived
on the scene four minutes after being called. An ambulance
Emergency Medical Services (EMS) crew also responded, arriving
at the scene nine minutes after 911 was called.
The
EMS crew gave the injured worker oxygen, applied MAST pants
(Military Anti-Shock Trousers to restrict blood-flow to and
from the lower extremities), set up a cardiac monitor and
attempted to establish an I.V. After ten minutes of EMS treatment
at the scene of the injury, the injured worker was transported
to an acute care general hospital within twelve minutes (at
approximately 8:22 a.m.). The amputated foot was placed in
a plastic bag, put on ice and transported to the hospital
with the patient. Because of extensive tissue damage, the
hospital did not attempt to surgically reattach the foot.
The injured worker was admitted to the hospital for one week.
At the time of the NURSE interview she was still at home,
and unsure of whether she would be able to return to work.
PREVENTION STRATEGIES
- Employers
should insure that guards on moving machinery are not easily
removed. Immediately after the incident, the company welded
the smaller portion of the protective grate to the adjacent
grate so that two people are needed to lift the grate free
of the trough lips. In this incident, if heavy equipment
had been required to move the grate it might not have become
dislodged.
- Employers
should consider using safer materials when designing, installing
and upgrading equipment. The auger could be made from lighter
and more flexible materials such as hard rubber, high technical
grade plastic, or flexible wire which would give way (e.g.:
bend, stop) upon contact with a person's hand or foot. Some
or all of these materials are feasible in vegetable processing
plants since the material being moved is vegetable matter,
and does not need a heavy metal screw to push it down the
trough. In this incident, if the auger had been made of
a more flexible material it might have given way when the
worker's foot contacted it, resulting in a less severe injury.
- Employers
should consider safety engineering when designing, installing
and upgrading equipment in a processing plant. The auger
should have a shut-off switch within immediate reach of
employees in the work area. Cord-type or other emergency
off switches can be easily installed at intervals adjacent
to the conveyor system. (The company is currently researching
the feasibility of installing more accessible shut-off switches
in a new plant.) Although stopping the equipment earlier
may not have prevented the loss of the worker's foot, it
would have prevented co-workers coming to her aid from being
exposed to the same hazard.
- Employers
should consider using automatic power shut- off switches
when designing, installing and upgrading equipment in a
processing plant. An electrical interlock system could be
installed with micro-switches at the contact points of the
grate so that the removal of the protective grate would
turn the rotating auger off. In this incident, if an interlock
system had been installed the auger would have stopped turning
when the grate was removed or dislodged, resulting in a
less severe injury.
- Employers
should consider using safer, innovative methods when designing,
installing and upgrading equipment in a processing plant.
A multi-jet re- circulating water wash system can be installed
in the waste troughs in place of the auger. In this incident,
re- design using water would have removed entirely the hazard
of the moving auger.
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(COHP)-FI-92-005-11
,
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: May 1992.
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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