A 20-year-old man was working by himself changing a press punch at a small machine shop when a welded hydraulic hose coupling blew, killing him instantly. He had returned the press cylinder to its full return position when pressure built up in the press’s hydraulic system and the fitting exploded. The burst fitting entered the young man’s body at the collarbone, as he was bent over the front of the press, and came to rest inside his body in the area of his lower back.

The boss found his young employee soon after the incident and called 911. The victim was pronounced dead at the scene. The investigation discovered that the hydraulic pressure gauge on the press was damaged and not working at the time of the incident.

The young man had not been certified by any safety standards. He should have received adequate training for working with high-pressure equipment. The hydraulic fittings should have been guarded to protect press operators. The gauge should have been operating and the broken fitting replaced rather than welded. Older pieces of equipment should be checked to ensure they adhere to current safety codes.

Source: Oregon Fatality Assessment and Control Evaluation (FACE) Program, Case Report:04OR015