Unintentional movement of a ram (during maintenance)…

When we visit aluminum plants on our global tours we ask to speak to maintenance department personnel. Why? We are we asked would we want to speak to the maintenance department. Because no other department faces as many different hazards on a daily basis then maintenance. Many times our presentations will be given at the end of one shift and then the beginning of the next shift. What do we talk about? We talk about the importance of following your training, never making assumptions, and never skip steps. Out all the traveling we do, we feel that these presentations are the most rewarding. It is our sincere hope that just as with this blog, that our presentations to maintenance departments prevent an incident from occurring. We will talk about this incident (without naming the company nor location) and discuss what had occurred and how to prevent a similar incident.

A maintenance worker was crushed fatally by a 4,000 pound machine part while performing maintenance inside of a sand core machine at an aluminum foundry.

An investigation by the U.S. Department of Labor's Occupational Safety and Health Administration found his employer, did not use lockout devices and other machine safety procedures to prevent unintentional movement of the part - known as a ram - while the worker was inside the machine. OSHA cited the company for one repeated and five serious safety violations on in July 2016, after the agency completed its investigation into the February 2016, death.

"An employee who had been with the company 40 years lost his life because his employer failed to follow safety procedures to prevent machine parts from moving during maintenance," said OSHA's acting area director. "Foundries have inherent dangers and employers like (company) need to review their safety procedures to protect workers on the job."

While investigating the fatality OSHA found the company:

• Failed to isolate all sources of energy in or to the equipment.
• Did not protect employees from unexpected machine movements during maintenance.
• Lacked machine-specific lockout procedures.
• Failed to adequately train workers on proper lockout procedures.
• Failed to coordinate lockout procedures with an outside contractor.
• Did not correct illegible markings on a crane pendant control box.

Proposed penalties total $105,000.

The company has 15 business days from receipt of its citations and penalties to comply, request an informal conference with OSHA's area director, or contest the findings before the independent Occupational Safety and Health Review Commission.

The Aluminium Plant Safety Blog offers our sincere condolences to the deceased worker’s family, friends, and coworkers.

We can assume that that everyone at that plant knew the worker because of his 40 year service with the foundry. We encourage that the aluminium foundry on regular basis offers counseling to their current workers. Their pain, their sadness will not go away in months and maybe not even years. On many occasions workers have approached us and offered their stories on how their coworkers passed away. In most cases we are at loss on what to say, but we listen to their entire story. Many times that is all that they ask. Is for someone to listen to their story. That is why the Aluminium Plant Safety Blog recommends mental health counseling after an incident.

As with any incident, there are multiple root causes that on that fateful day aligned resulting in the machinery starting up while the maintenance worker was inside. We recommend a last line defense when dealing with lockout tagout situations. Where a customized device (beam, pipe, etc.) is fabricated and can be installed to ensure that if the machinery starts up that device will prevent the worker from being injured. In this incident a “ram” unexpectedly moved resulting in the death of the worker. It is assumed that the ram is hydraulically powered. The ASPB has posted incident after incident on the unexpected release of a hydraulic ram. Resulting in decapitations, amputations, injuries and fatalities. If your plant has a machinery that has hydraulic rams it is imperative that lockout tagout procedures include the physical restraint of that ram to prevent unexpected movement.

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