A food production worker employed at a pizza dough manufacturing plant was killed when he was struck in the neck by the steel blade on a dough machine.

The victim and a co-worker were assigned to clean a dough machine. The facility’s lockout/tagout procedure required an operator to set the control buttons of one machine to “off” and “manual” before turning off the main power switches. Prior to the incident, the victim turned off and locked the power switches, but left the controls set to “on” and “automatic.” In order to clean the outside of the bowl, the co-worker had to have the bowl raised. He went to the victim and asked him for the key to unlock the main power switch. At this point the victim was in the middle of cleaning the inside of the hopper. He was standing on a metal step, bending over and extending his head through the bottom opening of the hopper while wiping the inside of the hopper with a rag. When asked, the victim gave his key to the co-worker. The co-worker walked to the control panel, unlocked the main power switch, turned it on and started raising the bowl. A few seconds later, the co-worker heard noises made by the victim. He immediately pushed the emergency stop button to stop the machine. The co-worker rushed to the victim and saw that the victim appeared to be partially decapitated from behind by the energized steel blade.

It’s important for regular inspections to be conducted to make sure lockout/tagout procedures are being strictly followed. These procedures must include specific steps for shutting down equipment. Cleaning procedures should be modified to avoid placing the worker’s body in the point of operation and interlocks should be installed to protect against possible human error.