Machine operator fatally struck by safety block ejected from mechanical power 

press (Case # 16NY064) 

NAICS: 335991/Carbon and Graphite Product Manufacturing

Key Words: press, flying object, machine guarding, struck by, safety blocks, projectile, 

SUMMARY 

On December 6, 2016, a 49-year-old male worker at a busbar manufacturing facility 

was fatally injured while operating a 200-ton press around 11:20 AM. The decedent and 

another employee were in the process of making busbars, a component of electrical

devices, out of raw copper strips using a 200-ton mechanical press. The press 

frequently jammed, requiring the decedent to place two safety blocks between the ram 

and bolster and reach into the press to unjam the machine. The decedent would then 

remove the safety blocks and return to actuate the machine at a dual-button control 

panel mounted to a pedestal, placed in front of the long side of the press. The decedent 

and the shift supervisor had to unjam the press multiple times. The last time they 

removed the jam, the safety blocks were unintentionally left on the bolster bed. The 

decedent, who was standing in front of the press by the pedestal controller, actuated the 

press. The two safety blocks were immediately ejected from the press; one block struck 

the decedent in the neck and chest inflicting severe injuries. Immediately after the injury, 

911 was called, and another employee tried to help with basic first aid. Emergency 

medical technicians (EMTs) responded in minutes, but the employee died at the scene 

due to blunt force injuries to the neck. 

INTRODUCTION

On December 6, 2016, a 49-year-old male worker at a busbar manufacturing facility 

was fatally injured while operating a 200-ton metal press around 11:20 AM. The New 

York State Fatality Assessment and Control Evaluation (NY FACE) staff learned of the 

incident from news media reports and contacted the employer to initiate an 

investigation. The employer did not respond to the NY FACE request. NY FACE also 

contacted the attorney who represented the manufacturer of the mechanical press 

involved in the incident to request for the press specification and information on 

operation and maintenance. The attorney declined to provide the information citing

trade secrets. The incident was investigated by the Occupational Safety and Health 

Administration (OSHA). NY FACE discussed the case with the OSHA compliance officer 

and reviewed the OSHA report as well as the death certificate. Additionally, NY FACE 

researched the technical information including safety block design, selection, and 

installation and reviewed the worker fatality cases associated with power presses on 

OSHA and FACE databases. This report was developed based on the information 

provided by OSHA and NY FACE research findings. 

EMPLOYER
The employer is a private international company with a non-union shop that has been in 

business for over a century as a producer of materials for the electric power industry 

such as high-speed fuses, busbars, surge protection, high and medium voltage fuses 

and bases, low voltage switches, and other types of electronics. The facility where the 

incident took place is a 110,000 square foot plant that produces busbars in a one-shift 

daytime operation. This is the second fatality that the employer had in the US within a 

two-year period; the previous fatality consisted of an explosion at a facility in another 

state that killed one person and injured another. 

WRITTEN SAFETY PROGRAMS AND TRAINING

The employer did not have specific written procedures for Lock-out Tag-out of 200-ton 

mechanical press, or other types of operating procedures for placing die blocks,

performing maintenance tasks, clearing jams, or other written safety procedures for 

utilizing the press. There was no documentation of employee training provided by the 

employer, but the employer did have a written health and safety program that was 

considered inadequate during the OSHA Fatality Inspection event after the incident 

occurred.

WORKER INFORMATION

The worker involved in the incident was a 49-year old white male. He had been 

employed by the company for about two months at the time of the incident but was a 

machine operator with twenty years of experience. He was assigned to work at the 200-

ton press. Training for the decedent consisted of verbal communication from an 

employee with experience in the operation of the press (shift supervisor). 

MACHINERY INVOLVED IN THE INCIDENT

The machine involved in the incident was a 

200-ton mechanical power press with a bed 

area that was 42 inches wide by 78 inches 

long (see Photo 1), which was powered by a 

combination of electrical and mechanical 

energies utilizing a flywheel. This press 

consisted of a stationary bolster plate (mount 

for die block that sits on the bed of the press) 

where raw material is placed, a ram (mount 

for die on the upper plate of the press) which 

moves in a vertical motion and forms or 

shapes raw material against the bolster plate 

into a finished product, and a frame that 

supports the structure of the press. Different 

types of dies can be mounted to the press that allow the press to manufacture finished 

products from different types of metals. Information regarding this press’s specifications 

Photo1: Mechanical Press involved in incident with light curtains

(Photo courtesy of OSHA)

Ram

Bolster

plate

Light 

Curtain

Interchangeable 

dyes
such as ram speed, specific pressures, shut height, capacities, etc., were not available 

for inclusion into this report.

This press was set up to run in individual pressings, or single cycle. Single-cycle press 

operation requires the operator to feed raw material into the press, align the material on 

the lower die block, then use a two-hand control to actuate the press. This press made 

its product from one-inch wide copper bands that were unwound from a coil at the 

beginning of the press, placed onto the bolster by the operator, and formed into 

busbars, which are pieces of copper used in electrical applications for power 

distribution, switchboards, and battery banks. After the press is actuated, the busbar

could be removed by the operator by reaching in between the ram and the bolster. 

The mechanical press was outfitted with a two-button control panel and an emergency 

stop. The two-button control panel required the operator to press both buttons on the 

control panel at the same time to actuate the press. This control is a built-in safety 

feature intended to prevent the operator’s hands from entering the point of contact when 

actuating the press. The two-button control panel was installed on a pedestal and

connected to the press with a long cord (see Photo 2). The pedestal could be moved to 

locations around the press allowing operator to have the best working view and easy 

access to the press. 

This press was retrofitted with light curtains due to the possibility for serious injury 

caused by the press when employees had to reach into the point of contact area

(between the ram and bolster plate). Light curtains are a type of machine guard that 

disallow the movement of the machine if they are blocked. The light curtains on this 

press were installed approximately 18 inches from the point of operation on both long 

faces of the press, where operators could physically reach into the press to remove 

materials or adjust die blocks.

Photo 2: Pedestal-mounted two-button controller for press actuation. (Photo courtesy of OSHA) 
Photo 3: Key-required controller mounted to infeed side of press (Photo courtesy of OSHA)

Additionally, the press had a keyed control box built onto the press along its 42-inch

wide face where raw material was fed into the press (see Photo 3). This control box 

required a key to switch press operational modes from “inch,” where the ram moves in 

small incremental movements for die set up and test cycles, as well as a “run” mode

which was for normal operation. The control box has an “off” selection, where the

control box would override the dual push button control panel mounted to the pedestal. 

INVESTIGATION

Prior to the incident, there was a near miss on the 200-ton press. Operators noticed that 

the ram would slowly start to slide down when the press was not being actuated by an 

operator. A third-party contractor came in and serviced the press by changing the clutch 

and rebalancing the press to prevent it from sliding on its own. Due to the near miss, the 

employer ordered the on-site fabrication shop to manufacture safety blocks to block the 

ram and prevent it from sliding without operator control, even though the press clutch 

had been repaired by the third-party contractor. Two safety blocks were furbished from 

aluminum available in house. The dimensions of the safety blocks were 16.75 inches 

long, 3 inches wide, and 3 inches deep. 

The use and deployment of these safety blocks was new at the time before the incident 

to all employees who worked at the 200-ton press, and no written procedures or 

methods existed for how to place the safety blocks between the ram and bolster.

Neither the shift supervisor nor the decedent had been trained on how to properly use 

the safety blocks prior to the day of the incident. Both had been instructed to use the 

safety blocks during operations that involved reaching in under the ram of the press.
The day of the incident, the press was frequently jamming. The decedent and the shift 

supervisor noted that jamming became more frequent as the spooled copper for busbar 

manufacturing got smaller. The two employees would cycle the press, place the safety 

blocks between the ram and bolster on the side of the press closest to the operator,

remove jammed copper by reaching in under the ram and pulling it out by hand, feed

fresh copper onto the die block by hand, trim the copper at the spool, remove the safety 

blocks, and cycle the press again. The two-button pedestal used for actuating the press 

had been moved to a position in front of the long side of the press, presumably for 

better line of sight and easier walking distance between the operator and the press. A 

visual representation of the layout prior to the incident is shown in Figure 1. This 

procedure of cycling the press and removing jams happened several times. The last 

time it happened, the safety blocks were left between the upper and lower die sets 

(plates that hold the die blocks) after the jam had been cleared and copper was fed 

through. The decedent, who was standing in front of the long side of the press by the 

pedestal controller, actuated the press. The two safety blocks were immediately ejected 

from the press: one block struck the decedent in the neck and chest inflicting severe

injuries. Another employee tried to help with basic first aid, but the injured employee 

was heavily bleeding internally. Immediately after the injury, 911 was called, and 

another employee tried to help with basic first aid. Emergency medical technicians 

(EMT) responded in minutes, but the employee died at the scene due to blunt force 

injuries to the neck.

Photo 4: In-house fabricated aluminum safety blocks with 

deformed corners and scraped metal face (Photo courtesy of 

OSHA)

Photo 5: Picture of mechanical press ram indicating where safety 

block had been placed. (Photo courtesy of OSHA)
Figure 1. Overhead view of the incident scene

Post incident examination of the ejected safety blocks revealed that block deformation 

was limited to corners of the 3-inchx3-inch block face, indicating that uneven pressure 

was exerted on the block. This was likely caused by the positions of the blocks which 

were not aligned with the longitudinal central axis of the ram (Photos 4 and 5). The 

uneven pressure exerted by the press contributed to the blocks to be forcefully ejected, 

striking the victim. 

According to OSHA, the decedent had been told to place the safety blocks towards the 

middle of the press by personnel with more experience, but this was not included in any 

written program. The light curtain did not stop the press from cycling because the 

operator was outside its 18 inch-detection perimeter around the press.

CAUSE OF DEATH

According to the medical examiner, the decedent died of blunt force injuries of the neck.

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. The NY FACE investigation 

identified the following key contributing factors in this incident:

• Safety blocks were left in the press when the press was actuated. 

• Safety blocks were not interlocked to the press circuitry. 
• Safety blocks were not aligned with the longitudinal central axis of the 

ram, causing a pressure difference between the two halves of the press. 

• The operator was in the path of the projectile. 

• No written procedures for setting up the machine, placing dies, clearing 

jams from the machine, or locking out the machine existed for reference 

by the operator(s).

• Limited training on the press was given to the decedent prior to his 

utilization of the press.

RECOMMENDATIONS

Recommendation #1: Employers should ensure that interlock devices are used in 

conjunction with safety blocks when working with mechanical power presses.

Discussion: The safety blocks in this case were not interlocked with the power press. 

The safety blocks were left in the press unintentionally and became projectiles when the 

press was actuated causing the fatal injury. The incident would have been prevented if 

the safety blocks had been interlocked with the 200-ton press. 

An interlock is a device that prevents unexpected or undesired movement of an 

energized machine through altering or impeding the flow of electrical energy to a 

machine when the interlock is disengaged. Regarding the mechanical power press, 

interlocks can be used to prevent machine actuation when physically attached to other 

manual safety devices, such as safety blocks, which when deployed would require the 

user to physically unplug the safety block from the interlock, which would in turn prevent 

the machine from actuating. The press would not have been able to operate again until 

all safety blocks were returned to their housings and plugged back into their interlock 

devices due to the disruption of electrical energy between the controls and the 

mechanical press. 
The American National Standards Institute 

(ANSI) Standard B11.1-2009, section 6.13 

talks about the requirements of safety blocks 

regarding mechanical power presses: 

“Safety blocks, slide locks, or other die 

support means shall be designed, 

constructed and installed to either: a) hold the 

full working force of the mechanical power 

press and tooling members when machine 

actuation can take place while the 

mechanism is in place; or b) be interlocked 

with the mechanical power press to prevent 

actuation of hazardous motion of the machine 

while in place in its protective position and be

designed and constructed to hold the 

maximum anticipated load.”

Several safety blocks are available on the 

market that include interlocks to avoid 

mechanical press cycling when the safety 

blocks are deployed. Safety blocks for mechanical presses are typically metal cylinders 

composed of an aluminum alloy with attached plugs on chains for interlock mechanisms 

(Photo 1). These plugs form the interlock system which when placed in-line with the 

press’s circuitry, prevent press actuation when the safety blocks are not plugged in. 

Slide locks are another type of mechanical device like safety blocks that can be installed

on the vertical portion of mechanical presses to support the ram. Like safety blocks, 

slide locks must also be designed to support the full static weight of the ram and all 

attached accessories, such as die blocks. Slide locks also require safety interlock 

devices to prevent unintentional press operation and/or be designed to withstand the full 

dynamic load of the press when actuated. Safety blocks and slide locks that can also 

stand up against the dynamic force (force when press is actuated), provide even further 

protection against electrical and mechanical safety failures. 

Recommendation #2: Employers should ensure that the selected safety blocks 

meet the rated capacity of the specific power presses.

Discussion: Blocks can be purchased to support the full static weight of the 200-ton 

press ram and should be engineered to have sufficient contact area for ram support. 

Depending on the anticipated load of the press, up to four safety blocks may be 

required to withstand the static load of the ram.

Photo 1: Example of safety blocks with interlock devices 

(Photo from EHSToday.com)
The employer in this case did not consult with the press manufacturer about the 

appropriate specifications and requirements of the safety blocks, such as the size, 

height, and material strength as well as the number of the safety blocks needed for this 

press. 

Recommendation #3: Employers should place safety blocks centered along 

middle length of press when servicing. 

Discussion: By placing safety blocks centered along the central axis of the press, any 

difference in pressure in the ram would be prevented. In this case the safety blocks 

were placed on one long side of the ram closest to the operator, so when the press was 

actuated, the force of the ram created a pressure differential between the two halves of 

the press, causing one side of the ram to press unevenly, applying shear forces to the 

safety blocks that ejected the safety blocks from the press.

Another option for employers would be to use safety blocks on all four corners of the 

press to ensure that the pressure is distributed evenly across the ram. This would

prevent any uneven depression that would unevenly deform safety blocks or force them 

out from between the ram and bolster.

Recommendation #4: Employers should ensure that press controls are moved to 

short ends of press to avoid risk of being struck by materials ejected during 

press operation.

Discussion: At the time of the incident, the decedent was standing by the controls in 

front of the long side of the press. Controls for this press are on a chord and can be 

maneuvered to several positions around the press. Keeping the press controls by the 

spool of raw material as it enters the press keeps employees out of areas where 

material could be more likely to be ejected from the press and allows more opportunity 

for guarding around the operating area. Additionally, the keypad that controls press 

speed and cycle type is located on the short end of the press where raw material is 

uncoiled and fed into the press. Keeping all points of control within the operator’s reach 

allows the operator to control press movement through the key-operated control system 

as well as maintaining control of press operation through the two-button control 

pedestal.

Recommendation #5: Employers should design machine guarding that allows for 

the safe movement of all employees around active machinery.

Discussion: Besides light curtains, the long sides of the press involved in the incident 

were unguarded in order to allow employees to access the point of contact when they 

were required to manually remove finished product, remove scrap metal, or adjust and 

retool die blocks. There is no hard guard or barrier that would prevent ejected materials 

from hitting employees or other nearby personnel. In order to eliminate the risk of 

unintentionally hitting employees with ejected materials, the employer could build a fixed 

guard such as a cage around the press to prevent ejected materials from contacting 
employees during normal production or other press actuation. The cage could have 

doors or gates built into it for access with machinery or personnel. Those doors and 

gates could also be interlocked to prevent machine actuation while guards were 

opened.

Recommendation #6: Employers should deploy a maintenance and inspection 

schedule of mechanical presses.

Discussion: During this investigation, it was determined that the press was not being 

maintained in compliance with the recommended maintenance schedule which included 

weekly, biweekly, monthly, and annual checks for the Heim press. Only monthly 

maintenance checks were performed and documented on a card attached to the press.

Frequently inspecting mechanical press components for wear, operability, or other 

abnormality allows maintenance staff to continuously upkeep machines so that machine 

safety and performance features are operating correctly. Mechanical presses and other 

energized machines should be inspected and adjusted routinely in line with the 

manufacturer’s suggested maintenance intervals. The manufacturer of the press 

involved in the incident has written instructions in the press manual regarding scheduled 

maintenance and inspection requirements. This information is often listed in the 

operating manuals of mechanical presses and other types of machinery. Employers 

should ensure that routine maintenance and inspection practices on mechanical 

presses are implemented. 

Recommendation #7: Employers should ensure employees are thoroughly trained 

on machines they operate.

Discussion: During the investigation, it was determined that the decedent and the shift 

supervisor were not adequately trained on the procedural change to use safety blocks in 

between press actuations while troubleshooting, which contributed to the cause of the 

incident.

Employers should ensure that employees are knowledgeable in the safe operation of 

machinery and should ensure employees are aware of the tasks involved with operating 

machinery, especially high-risk activities where there is an elevated chance of injury. 

Employers should ensure operators read the manual for machines they are required to 

operate, and are knowledgeable in the machine’s workings, capacities, and potential 

troubleshooting requirements. When procedural changes occur, all parties involved with 

the operation and maintenance of the machine should be trained on the changes. 

Routine retraining and testing should occur to ensure that machine operators 

understand and maintain their knowledge on the machines they use.

Recommendation #8: Employers should conduct Job Hazard Analyses (JHAs) for 

specific tasks and instruct employees on how to safely work with and 

troubleshoot machinery issues during normal production operations.
Discussion: No specific procedures such as JHAs existed prior to the incident that 

described safe methods for setting die blocks, clearing jams, or otherwise performing 

specific operations and maintenance tasks on the 200-ton press that kept press 

operators out of harm’s way. JHAs can establish specific methods for safely setting die 

blocks, clearing jams, or otherwise working on the press, while also addressing potential 

hazards such as caught between, struck by, fall, or harmful exposure hazards (including 

hot surfaces). Additionally, JHAs can implement procedures that specify what to do with 

operable controls of machinery while troubleshooting. For example, placing the key 

control in “off” when actively working in the point of contact area when setting up or 

adjusting die blocks. 

Recommendation #9: Employers should train employees in Lock-out Tag-out 

(LOTO) procedures. 

Discussion: During the OSHA investigation, it was determined that press operators 

were not trained in LOTO procedures, and that only maintenance personnel were LOTO 

certified. Also discovered during the investigation was the use of only one lock on LOTO 

points despite multiple employees working on the same machine. All personnel working 

on a mechanical press or other machine should place their own lock on energy isolation 

points for mutual protection against unintentional or unknown machine re-energizing. 

Locks and tags should clearly indicate who they belong to. This then requires all parties 

working on the machine to be aware of when the machine is and is not locked out and 

actively protects all participants in maintenance or other activities that require lockout 

tagout.

DISCLAIMER

Mention of any company or product does not constitute endorsement by the NY FACE 

and National Institute of Occupational Safety and Health (NIOSH). In addition, citations 

of websites external to NY FACE and NIOSH do not constitute NY FACE and NIOSH 

endorsement of the sponsoring organizations or their programs or products. 

Furthermore, NY FACE and NIOSH are not responsible for the content of these 

websites. All web addresses referenced in this document were accessible as of the 

publication date.

REFERENCES

American National Standards Institute (ANSI). Safety Requirements for Mechanical 

Power Presses. ANSI B11.1-2009 (R2014). 

Michigan Fatality Assessment and Control Evaluation Program. “Co-Owner of Metal 

Forge Shop Dies When an Ejected Piece of Steel Used as a Stop Block in a Full 

Revolution Press Strikes Him in the Chest.” Retrieved July 30, 2020 from 

https://www.cdc.gov/niosh/face/stateface/mi/03mi029.html
NIOSH. Injuries and Amputations Resulting from Work with Mechanical Power Presses. 

Retrieved July 30, 2020 from https://www.cdc.gov/niosh/docs/87-107/default.html

OSHA. Machinery and Machine Guarding, Mechanical Power Presses. 

29CFR1910.217. Retrieved July 30, 2020 from https://www.osha.gov/lawsregs/regulations/standardnumber/1910/1910.217

OSHA. Osha Instruction: Slide Locks-Enforcement Policy, Inspection Procedures and 

Performance Guidance Criteria. Retrieved July 30, 2020 from 

https://www.osha.gov/OshDoc/Directive_pdf/CPL_02-01-043.pdf

OSHA. Control of hazardous energy (lockout/tagout). 29 CFR 1910.147. Retrieved July 

30, 2020 from https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.147

OSHA. Hazards Associated with the "Unintended (Double) Cycling" of Mechanical 

Power Presses. Retrieved July 30, 2020 from

https://www.osha.gov/dts/shib/shib020210.html

Hale, Carrie. 2017. Die Safety Blocks: Why They’re Needed and How To Use Them

Retrieved July 30, 2020 from https://www.ehstoday.com/safety/article/21917888/diesafety-blocks-why-theyre-needed-and-how-to-usethem#:~:text=With%20the%20press%20motor%20off,weight%20the%20blocks%20mus

t%20support. 

Rockford Systems, LLC. Safeguarding Mechanical Power Presses. Retrieved July, 30, 

2020 from https://www.rockfordsystems.com/safeguarding-mechanical-power-presses/

INVESTIGATOR INFORMATION 

This investigation was conducted by NY FACE, Bureau of Occupational Health and 

Injury Prevention, Center for Environmental Health, New York State Department of 

Health.

ACKNOWLEDGEMEMENT

The NY FACE Program would like to acknowledge the OSHA Buffalo Area Office for 

providing assistance and information for this investigation.