Two new fatality investigation reports from OR-FACE

OR-FACE contractors Illa Gilbert-Jones and Steve Eversmeyer have published two new Fatality Investigation Reports this summer: “Rubber equipment operator died after his head was caught between bars of operating machinery,” and “Maintenance Mechanic Crushed Working Inside of a Vertical Storage Machine.” A summary of each is below.

Rubber Mill:
A rubber cutter was found caught between two bars of a festoon rubber processing line (cooling line). The event was unwitnessed; however, circumstances suggested that the employee entered the festoon area to retrieve and redirect a rubber strip on a cooling bar that had passed the point where it should have fed onto a conveyor. It is believed that the worker raised his head between the moving cooling bars, and that the bars then forced his head against a structural support for an electrical panel. He was pronounced dead at the scene.


  • Safeguard machinery to protect machine operators and others who work in the area from hazards.
  •  Implement, enforce, and assess “control of hazardous energy (lockout/tagout)” procedures for machines, equipment and processes where unexpected energization or start-up could cause harm to personnel.
  • Establish a safety committee that meets the requirements of Oregon Occupational Safety and Health Administration (OSHA).
  • Confirm industry best practices for specialty equipment, and notify equipment manufacturers of equipment hazards identified in hazard assessments.


Vertical Storage:
A Certified Field Technician was killed after he climbed into a mechanical vertical storage unit to facilitate repairs. He had a new, inexperienced employee with him on the day of the incident; the Technician was training the new employee. The Technician lay inside the machine, and as the trainee cycled the machine to put the Technician in a position to conduct repairs, the machine malfunctioned. The Technician asked the trainee to make another input to the controls. The machine advanced the Technician over the top of the vertical storage unit, which had very limited space. This action crushed the Technician, leaving him on the sealed side, opposite the side where he started. Pry bars were used to extricate the Technician but resuscitation attempts failed.


  • When selecting and installing equipment, ensure that maintenance can be performed without exposing employees to hazards. Making safe access easier and quicker will encourage safer work practices.
  • Follow lockout/tagout procedures to reduce the risk of hazardous movement of machines prior to work in a confined space, and seek advice or consult the machine manual if unsure how a task can be accomplished in a de-energized machine (e.g., hand crank).
  • Employers should never allow entry into a confined space that contains physical hazards until there is a positive movement control method developed.
  • Routinely assess job hazards, provide regular, periodic training and communications on site-specific hazards and safe work practices, and take corrective action when needed. Check and monitor employees’ knowledge of job hazards and implementation of safe practices to control hazards.
  • Ensure the equipment manual is available and reviewed prior to working with equipment.
  • Provide appropriate audits of lockout/tagout use (annually at a minimum).
  • Equipment/Facility owners should ensure safe work practices are followed, and inform contractors and their employers when discrepancies are observed.