FACEValue: Millwright killed when pinned between feed rolls of a debarker

NIOSH's Fatality Assessment and Control Evaluation Report
#2006-02
Date of incident: Jan. 17, 2006

A millwright was killed while welding additional metal to the feed rolls of a debarker at a lumber mill. The worker had not performed this type of repair prior to the day of the incident, and his supervisor had left him alone to perform the job. He locked out two electrical disconnects before starting the task. The victim did not lock out all of the electrical disconnects, and the airline to the machine was not locked out and shut off. The feed rolls on the machine closed over the head of the victim as he was reaching forward to access areas that required more metal. The supervisor returned to find the victim pinned between the feed rolls of the machine. Emergency medical services arrived and performed CPR, but the victim was pronounced dead at the scene.

To prevent future occurrences:

• Employers should ensure hazardous energy control procedures clearly identify all potential sources of energy for each machine and the location and method for control is clearly identified. The hazardous energy control procedures were not sufficient to completely de-energize and lock out the debarker. These procedures should clearly state how workers should obtain sufficient locks and keys to lock out all hazardous energy sources present.
• Employers should follow the equipment manufacturer’s recommendations for removal, maintenance, repair and replacement of machine parts. Debarkers have large rolls with metal teeth that can wear over time. These rolls are not easily accessible and move under electrical and air power. The manufacturer recommends that a representative be called to remove and replace worn feed rolls.
• Ensure employees are adequately trained and supervised when assigned to perform new, infrequent or dangerous tasks.