Case Study

The plant is experiencing some difficulties with a clamping device on a holding fixture that keeps a metal part in positions while it is fed into an automatic stamping machine. The clamp does not always allow the metal part to be fed into the machine properly aligned. The worker who was operating the machine had 32 years' experience with this type of equipment.

While attempting to make the necessary adjustments for smooth operation without shutting off the power, she had to reach into the machine. She placed her left hand between the feed-in mechanism levers while her right hand was positioning the misaligned part between the open clamps of the fixture.

Unfortunately, the one -button actuating control was located immediately to the left of the worker's body, about hip level. The worker inadvertently depressed the button with her leg, while reaching into the machine. The machine cycled, the feed mechanism slid forward while the fixture clamps closed. The worker had a portion of her left middle finger amputated.

From this case study, answer the following questions:

1. Were there any unsafe acts. If so what were they?

2. Were there any unsafe conditions. If so what were they?

3. Were there any chance occurrences. If so what were they?

4. Based on the information you have gathered, what steps would you take to prevent this situation from happening again?