FATALITY INVESTIGATION REPORT

DATE: 

August 23, 2018

TIME:

2:45 p.m.

VICTIM:

23-year-old male Rubber 

Cutter

INDUSTRY/NAICS CODE:

Manufacturing/32

EMPLOYER: 

Custom rubber 

compounding and 

processing 

SAFETY & TRAINING:

Safety meetings & training 

facilitated by employer

SCENE: 

Festoon (cooling line)

LOCATION:

Oregon

EVENT TYPE:

Caught in or between

INCIDENT HIGHLIGHTS 

 

Rubber equipment operator died after his head was 

caught between bars of operating machinery 

REPORT#: 2018-29-1 REPORT DATE: June 2019

________________________________________________________

SUMMARY 

On August 23, 2018, a 23-year-old male Caucasian rubber cutter was found 

caught between two bars of a festoon rubber processing line (cooling line). 

The event was unwitnessed; however, circumstances suggested that the 

employee entered the festoon area to retrieve and redirect a rubber strip 

on a cooling bar that had passed the point where it should have fed onto a 

conveyor. It is believed that the worker raised his head between the 

moving cooling bars, and that the bars then forced his head against a 

structural support for an electrical panel. He was pronounced dead at the 

scene. (Full report begins on p. 3) 

________________________________________________________

CONTRIBUTING FACTORS 

Key contributing factors identified in this investigation include: 

 Inadequate equipment safeguard 

 Inadequate lockout/tagout program and training 

 Inadequate hazard assessment and knowledge of safeguarding 

equipment 

 Inadequate training and assessing workplace hazards 

______________________________________________________ 

RECOMMENDATIONS 

Oregon Fatality Assessment and Control Evaluation (OR-FACE) 

investigators concluded that to help prevent similar occurrences, 

employers should: 

 Safeguard machinery to protect machine operators and others who 

work in the area from hazards. 

 Implement, enforce, and assess “control of hazardous energy 

(lockout/tagout)” procedures for machines, equipment and processes 

where unexpected energization or start-up could cause harm to 

personnel. 

 Establish a safety committee that meets the requirements of Oregon 

Occupational Safety and Health Administration (OSHA). 

 Confirm industry best practices for specialty equipment, and notify 

equipment manufacturers of equipment hazards identified in hazard 

assessments. 
Page 2

OR-FACE supports the prioritization of safety interventions using a hierarchy of safety controls, 

where top priorities are hazard elimination or substitution, followed by engineering controls, 

administrative controls (including training and work practices), and personal protective equipment. 

Oregon Fatality Assessment and Control Evaluation (FACE) Program

The Oregon Fatality Assessment and Control Evaluation (OR-FACE) Program is a project of the Oregon 

Institute of Occupational Health Sciences at Oregon Health & Science University (OHSU). OR-FACE is 

supported by a cooperative agreement with the National Institute for Occupational Safety and Health 

(NIOSH) (grant #U60OH008472) through the Occupational Public Health Program (OPHP) of the Public 

Health Division of the Oregon Health Authority. OR–FACE reports are for information, research, or 

occupational injury control only. Safety and health practices may have changed since the investigation 

was conducted and the report was completed. Persons needing regulatory compliance information 

should consult the appropriate regulatory agency.

ma.face@state.ma.us

m
REPORT#: OR 2018-29-1 Page 3

INTRODUCTION

On August 23, 2018, a 23-year-old rubber cutter was killed when he attempted to retrieve a rubber strip on the cooling 

line (Festoon, see photos 1 and 2) that had passed the point where it should have been fed onto a conveyor. He raised 

his head between two horizontal bars, and as the line began to move, it forced his head against the electrical panel 

support. OR-FACE received notification of the incident from Oregon OSHA (OR-OSHA). This investigation report is based 

on OR-FACE site visit with an OR-OSHA investigator, review of OR-OSHA investigation documents, follow-up discussions 

with the OR-OSHA investigator, and best practices research. 

BACKGROUND

The rubber industry uses powerful machinery that has the potential to cause fatalities and serious injuries. Serious 

incidents may take place during repairs or to clear blockages, if proper safety procedures are not followed, including deenergizing the equipment. Mechanical hazards include rollers, conveyors, rotating equipment, power feeders, and 

cutting blades. 

EMPLOYERS 

The decedent worked at a custom rubber compounding and mixing facility. The corporation has been in business for 

approximately 50 years and employed a total of 79 employees at the time of the incident, including full-time and parttime employees. There were 35 employees working on site on the day of the incident. 

WRITTEN SAFETY PROGRAMS and TRAINING 

The company safety programs included monthly safety and environmental meetings with documented minutes. There 

was no indication of quarterly safety inspections. A training guide was created for each position, e.g., rubber cutter, 

chemical compounder, mixer operator. The guide outlined purpose and scope, responsibility, and safety. Items listed 

under “safety” included emergency response, personal protective equipment, lifting, and forklift operation. The 

Production Supervisor maintains the training guide with employee signature obtained once trained. A written Control of 

Hazardous Energy (Lockout/Tagout) Procedure contained required regulatory elements with photographs of equipment, 

procedure, and energy source. The Company’s Lockout/Tagout procedure listed “authorized” personnel, who were 

management/supervisors, and maintenance staff (millwright, welder/fabricator). As defined in the OSHA standard and 

stated in the procedure, “authorized” personnel, were to be trained in the “recognition of applicable hazardous energy 

sources, type and magnitude of energy available...and the methods and means necessary for energy isolation and 

control. In accordance with the OSHA standard, the company procedure defined “affected” employees as all employees 

other than authorized employees utilizing the lockout/tagout procedure and that they shall be instructed in the purpose 

and use...” Operators, such as the decedent, were not included in the list of “authorized" personnel, therefore, not 

trained to de-energize or lockout equipment. 

WORKER INFORMATION 

The 23-year-old decedent had two years of experience working for this employer. Signed documents and interviews 

indicate that the employee was trained on different processes and listed as fully competent as a chemical compounder, 

rubber cutter, mixer, and lacer. 
REPORT#: OR 2018-29-1 Page 4

 INCIDENT SCENE 

On the day of the incident, the worker began his shift at 7:00 am. He was assigned to operate the cutter machine. 

Cutting is the initial station for that production line followed by the mixer station, and the drop and strip mill. During the 

process, heat is created, and the product must be cooled before preparing it for shipment. As the rubber strip leaves 

the process, it is laced onto the festoon for cooling. The “Rubber Lacer” operates the festoon and assures the strip is 

conveyed to the shipping area where it is placed onto pallets for shipment. The festoon (see Photos 1 and 2) was 

comprised of approximately 90, 1.5-inch diameter rods spaced approximately 4 inches apart, and approximately 59.5 

inches above the floor. These rods move parallel to the floor and reportedly were programmed to travel four inches 

every five seconds. The speed of the festoon allows segments of the strip to drop between bars in a serpentine action. 

As the laced rubber strips travel on the festoon, they pass the fans that blow air to cool the strip. The Operator/Rubber 

Lacer is expected to observe the rubber strips as they begin to rotate on the festoon. Once the strip starts on the 

festoon the operator then moves to the other side of the machine to ensure that the strip is directed onto the offloading conveyor for transport to the packaging/shipping area. 

Throughout the day, between batches, the decedent was observed walking through the process area asking other 

equipment operators if they needed help. At approximately 2:45 pm, the Rubber Lacer asked for assistance with the 

batch travelling on the festoon. Specifically, the decedent was asked to assure that the lead rubber strip was directed to 

the conveyor belt that feeds the product to the shipping area. The Rubber Lacer was waiting at the shipping area to 

observe the strip arrive on the conveyor. When it didn’t arrive as expected, he called out to the worker. After receiving 

no response, the operator went around to the other side of the machine to look for the worker and found him caught 

between two rods, unresponsive.

WEATHER

The weather was not considered to be a factor in the incident as it occurred indoors.

Photo 1. Unguarded festoon (cooling line) (Photo 

courtesy of OR-OSHA).

Photo 2: Schematic of festoon (cooling line)

(Photo courtesy of OR-OSHA).

rods/bars

cooling fans
REPORT#: OR 2018-29-1 Page 5

INVESTIGATION

There were no witnesses to the incident (the decedent was not within visual sight of the Rubber Lacer, who was at the 

other end of the festoon), and no one observed the worker entering the unguarded festoon area. It is speculated that 

the lead strip had passed the point where it would normally be fed to the conveyor and had made its way around the 

corner, where the worker likely entered the festoon. As the 

bars rotate around the corner of its elliptical path, the bars 

separate (see Photos 2 and 3) at the outside end. It 

appeared that the worker raised his head between two bars, 

and when the equipment began to rotate, his neck was 

caught between the bars, forcing his head against the control 

panel support. 

Upon finding the worker, the operator pressed the 

emergency button at the control panel to shut the system 

down, indicating that the machine had been energized. 

Moreover, records indicated that none of the operators were 

“authorized” to lockout any equipment. Some were trained 

as “affected” (awareness of LOTO program but not trained to 

de-energize or lock equipment) employees. 

There were other similar festoons on site. None were 

safeguarded to prevent entry into danger zones or contact 

with rotating bars/rods. Employees were allowed to reach 

into the machine to make minor alterations while operating. 

One of the festoons is situated near the locker room and employees walked passed rotating rods several times daily. 

According to the employer investigation report, unguarded festoons are common throughout the rubber industry. It is 

unknown if festoon manufacturers recommended guards/barriers or notified buyers of potential entanglement hazards. 

After the incident, the employer halted production until physical guards were installed (see Photos 4 and 5). 

In two safety committee meetings preceding the incident the following action item, related to a new festoon line being 

assembled, was listed: “call for OSHA consulation after new production line is installed. Check safety systems and ask 

questions about lockout tagout procedures.” 

Photo 3. Festoon corner section; note the distance between 

two bars (Photo courtesy of OR-OSHA). 

Back of 

control panel

Panel structural 

support
REPORT#: OR 2018-29-1 Page 6

CAUSE OF DEATH 

According to Oregon Vital Records data, the cause of death was neck injury.

CONTRIBUTING FACTORS 

Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger 

sequence of events that ultimately result in the injury or fatality. OR-FACE investigators identified the following factors 

that may have contributed to this incident: 

 Inadequate equipment safeguard, allowing entry into area of rotating equipment. 

 Inadequate lockout/tagout program and training. The program and training emphasized maintenance and servicing 

and did not consider operator actions that would require de-energizing to prevent contact with/avoid inadvertent 

movement of equipment components. 

 Inadequate hazard assessment and knowledge of safeguarding equipment, and based on a perception that the 

festoon was not hazardous, or as hazardous as other equipment. 

 Inadequate training and communication regarding hazards. There were no records of regular hazard inspections nor 

training on identifying hazards.

RECOMMENDATIONS/DISCUSSION 

 Recommendation #1: Safeguard machinery to protect machine operators and others who work in the area from 

hazards. The safeguard should prevent employees from having any part of their body in the danger zone during 

the machine operating cycle.

Photo 4. Installed guard at festoon line 

(Photo courtesy of OR-OSHA).

Photo 5. Installed guard with serpentine 

rubber strip visible (Photo courtesy of OROSHA).
REPORT#: OR 2018-29-1 Page 7

Discussion: Rubber manufacturing machinery are comprised of rolling machines, extruders, mixing and cutting. The 

employer’s primary focus prior to the fatality was safeguards for these equipment, which they may have believed to 

be more hazardous. However, any machine part, function, or process that may cause injury must be safeguarded. 

This includes slow moving machine parts like the cooling festoon. 

OSHA’s publication, “Basics of Machine Guarding” (see references), states that equipment safeguards must be 

secure such that workers cannot easily remove or tamper with the safeguard. The physical barriers (see Photos 4 

and 5) installed by the employer after the incident appeared to be secure and fixed. However, such barriers should 

not create interference. If the guard impedes the worker from completing his task efficiently and comfortably the 

guard will likely be overridden or disregarded. It was not determined in the investigation how often the rubber strip 

required redirection from the festoon line to the off-loading conveyor. When doing so, the safeguard must prevent 

hands, arms, and any other part of a worker’s body from making contact with hazardous moving parts. A tool to 

reach over the guards to capture and direct the strip may be a consideration. However, this action should not create 

new hazards.

Other possible safeguards include engineered systems such as light curtains or interlocks. When an interlocked 

guard is opened or removed, the tripping mechanism and/or power automatically shuts off or disengages, the 

moving parts of the machine are stopped, and the machine cannot cycle or be started until the guard is back in 

place. An interlocked guard may use electrical, mechanical, hydraulic, or pneumatic power or any combination of 

these. To be effective, all removable guards should be interlocked to prevent occupational injury hazards. Interlocks

allow access to the machine for removing jams without time-consuming removal of the fixed guards.

 Recommendation #2: Implement, enforce and assess “control of hazardous energy (lockout/tagout)” procedures 

for machines, equipment and processes in which the unexpected energization or start-up could cause harm to 

personnel. These activities may include, adjusting inspecting, unjamming, set up, testing, troubleshoot, servicing 

and maintaining machines, equipment or processes.

Discussion: Documents obtained in the investigation included the company’s “Control of Hazardous Energy 

(Lockout/Tagout)” Program. Those employees trained as “authorized” according to the OSHA standard, were 

management and maintenance personnel. Operators were to be trained as “affected” (defined in the OSHA 

standard) employees, although, interview notes disclosed that some operators did not recall the training or when to 

initiate the lockout/tagout (LOTO) process. The decedent entered the danger zone to retrieve the lead strip. The 

lead strip had gone well past the offload conveyor, requiring adjustments to redirect the strip. Had there been a 

physical barrier in place around the festoon, this task would have required entry into the danger zone; this would 

have required controls to prevent inadvertent movement of machinery. In many cases LOTO is associated with 

maintenance and servicing equipment and relegated to maintenance personnel; however, if operators are required 

to enter danger zones, they must be included as “authorized” employees in the LOTO program. Tasks associated 

with operating the machinery, and not just maintenance or servicing positions, should be assessed to determine 

when LOTO procedures should be initiated.

 Recommendation #3: Establish a safety committee that meets the requirements of Oregon OSHA. Specifically 

include requirements of quarterly inspections to identify and mitigate hazards, and including representatives from 

all major activities. 
REPORT#: OR 2018-29-1 Page 8

Discussion: Documentation of safety and environmental meetings were reviewed. These minutes were posted 

above the time clock as confirmed during interviews. According to Oregon OSHA, safety committees must have an 

equal number of employer-selected members and employee-elected (or volunteer) members and must include 

representatives from the major activities of the company. Based on the meeting minutes obtained, it did not appear 

that operators were represented on the committee. Additionally, according to interview responses, quarterly 

inspections may not have occurred. Critical to effective inspections by the safety committee is hazard identification 

training as required by Oregon OSHA and employee involvement in hazard mitigation. After the incident, the 

employer encouraged employees to report hazards. This particular action is one step in developing a foundation for 

a safe workplace. Refer to Oregon OSHA, “Foundations for safe workplace” and NIOSH “Elements of Effective 

Workplace and Policies for Improving Worker Health and Wellbeing” for guidance in sustaining a safety culture. 

 Recommendation #4: Confirm industry best practices for specialty equipment, notify equipment manufacturer of 

fatal hazards identified in hazard assessment. 

Discussion: Several references in the investigation documents, indicated that unguarded festoons were common 

industry practice. OR-FACE contacted the employer requesting information about the festoon cooling line 

manufacturer, but no response was received; therefore, OR-FACE was unable to contact the manufacturer. Online 

research of rubber compounding equipment manufacturers revealed only international companies. This only 

emphasizes the importance of buyers/users to assess safeguards on machinery especially those manufactured 

internationally. 

OR-FACE was unable to confirm from either American Chemical Society (ACS) – Rubber Division, or Association of 

Rubber Products Manufacturers (ARPM) whether festoons/cooling lines without safeguards is an industry practice. 

Association of Rubber Products Manufacturers replied that a majority of their members were molders not mixers. It 

is the intent of OR-FACE to forward this report to the industry and trade associations mentioned above.

DISCLAIMER

Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety 

and Health (NIOSH) or OR-FACE. In addition, citations to websites external to NIOSH or OR-FACE do not constitute 

endorsement of the sponsoring organizations or their programs or products. Furthermore, neither NIOSH nor OR-FACE is 

responsible for the content of these websites. All web addresses referenced in this document were accessible as of the 

publication date.

REFERENCES

Basics of Machine Guarding, US Department of Labor, OSHA 

https://www.osha.gov/Publications/Mach_SafeGuard/chapt1.html

Elements of Effective Workplace and Policies for Improving Worker Health and Wellbeing – CDC National Institute for 

Occupational Safety & Health 

https://www.cdc.gov/niosh/twh/essentials.html

Foundations of a safe workplace—Oregon OSHA 

https://osha.oregon.gov/OSHAPubs/4755.pdf
REPORT#: OR 2018-29-1 Page 9

Lockout/Tagout, Oregon OSHA’s guide to controlling hazardous energy -Oregon OSHA 

https://osha.oregon.gov/OSHAPubs/3326.pdf

Machine guarding eTool--US Department of Labor, OSHA 

https://www.osha.gov/SLTC/etools/machineguarding/guards.html

Oregon OSHA, Division 2, Subdivision O, Machinery and Machine Guarding (29 CFR 1910.211-1910.219); adopted by 

reference), 

https://osha.oregon.gov/OSHARules/div2/div2O.pdf

Oregon OSHA, Division 1, 437-001-0765 Safety Committees and Safety Meetings

https://osha.oregon.gov/OSHARules/div1/437-001-0765.pdf

Safety committees and safety meetings for general industry and construction employers—Oregon OSHA 

https://osha.oregon.gov/OSHAPubs/0989.pdf

US Department of Labor, OSHA “Machine Guarding Checklist”

https://www.osha.gov/Publications/Mach_SafeGuard/checklist.html

Weather Underground. https://www.wunderground.com/history/ 

Additional Resources: 

“Introduction to rubber processing and safety issues” – Health and Safety Executive 

http://www.hse.gov.uk/rubber/introduction-to-rubber-processing.pdf

“Guideline for safeguarding machinery and equipment” – WorkSafe BC, June 2008 

https://www.safemanitoba.com/Page%20Related%20Documents/uploads/guidelines/safeguardingmachineryequip.pdf

INVESTIGATOR INFORMATION 

This investigation was conducted by Illa Gilbert-Jones and Barbara L. Epstien from the OR-FACE Program. The report was 

reviewed and received input from Ryan Olson, PhD, Director, OR-FACE Program, and the OR-FACE Publications Review 

Panel. 

ACKNOWLEDGEMENT 

The Oregon FACE Program would like to acknowledge the compliance officer and staff of Oregon Occupational Safety 

and Health (Oregon OSHA), a division of the Oregon Department of Consumer & Business Services, for providing 

assistance and information during this investigation.