Papermill Employee Killed
At Winder Station

On February 9, 1998, a 40-year-old male employee died while working at a paper mill. The employee was working at the winder station, which is a spool-like machine on which the paper is wound. One complete roll of paper had been processed. When inserting the paper for the next roll, the victim noticed that the paper was not winding properly and entered the pit below the winder. Because of the large size of the equipment, components may be started up or turned off while machine tenders are out of sight of the operator. In this case, another employee, unaware that the victim entered the pit, assumed there was a problem and went to the back of the winder to turn off the lockout switch. When the lockout switch was turned off, a safety plate came down to prevent access, and the victim was pinned against the beam when the safety plate came down. The employee then went around the other side of the winder to enter the pit and noticed the victim was in the pit, pinned between the plate and the beam. The employee called for help, and the victim was taken to a local hospital, where he was pronounced dead.

1. Ensure that employees are trained in proper lockout / tagout procedures.

--Training in lockout / tagout procedure is crucial, since communication is often difficult due to high noise levels in factory settings.
--Because of the large size of this equipment, components could be turned On/Off while machine tenders were out of sight of the operator.
--It is essential to have clear line-of-sight to determine if the lockout switch can be activated safely.

2. Ensure that pit areas are adequately marked. The grated floor grid of the pit area should be painted with yellow stripes, adequate lighting installed, and signage placed outside the pit area.

--Safety marking and proper lighting can identify hazards to employees in the area.
--With adequate lighting in the pit area, an operator could more easily see if another employee was present.

3. Provide training and documentation on specific lockout procedures. A clear understanding of procedures should be provided in the training.

--Specific procedural steps for lockout should be provided in company training sessions.
--Training should identify if lockout is necessary every time an employee enters the pit area.
--There was an understanding that whoever turns the lockout switch is the one that enters the pit area, although this may not have been properly documented or understood.
--The roll handler (victim) was filling in for an excused employee, and had not worked previously with the core cutter. Re-training should be provided whenever there is a change in job assignments.