A shift supervisor in a paper mill bled to death after both his arms were caught between two paper machine rollers.

He entered an unguarded metal walkway that provides access to the area without first raising the top roller away from the bottom roller. He then began inspecting a woolen felt screen where it traveled over the roller, looking for the cause of a break in the continuous sheet of paper. It appears the victim’s hands were caught between the top and bottom rollers and his arms were pulled up into the machinery. A co-worker saw the victim was trapped so he activated a lever that raised the top roller, allowing the victim to fall to the floor. He died from blood loss shortly afterward.

The employer had a general written safety policy, but there were no detailed task-specific policies. Training was mostly conducted on the job and by video.

The supervisor had worked at the plant for seven years, the last four as shift supervisor, but his experience didn’t save him from a mistake that cost him his life.

Establishing standard lockout and tagout procedures, including detailed rules for de-energizing or isolating potentially hazardous energy sources such as the revolving rollers before inspections, might have saved him.

To prevent similar incidents, safety investigators recommended the employer:

• implement a new safety plan that included procedures specific to particular tasks.
• guard the access to hazardous areas with physical barriers or locked gates to protect workers from becoming entangled in the moving machinery.
• contact the manufacturer to get information about safety refits for the machinery, which was installed in more than 30 years previously and hadn’t been updated.
• review operations in their other plants and perform similar safety evaluations and upgrades.

The employer was encouraged to put danger signs in conspicuous places in hazard zones. At the time of the incident, the danger sign in the area was illegible.

The employer was also advised to conduct scheduled and unscheduled worksite inspections. Such inspections would reinforce the importance of safety on the job and underline the employer’s commitment to a safe workplace.