The maintenance foreman, another maintenance employee, and two laborers had been working on the remodeling project but at the time of the incident only one laborer was in the room with the victim. The co-worker ran outside the rendering room and yelled for help. He did not know the location for the auger on/off switch. It was on the wall approximately 2 ft (0.6 m) from the auger, about 7 ft (2.1 m) above the floor, and it was in the up or “on” position. Another worker just outside the rendering room responded, came into the room and turned off the wall switch for the auger. One employee reported that the auger switch had been used a long time ago, indicating that the wall switch may not normally have been used to turn the auger off and on.

The maintenance foreman had locked the main breaker control during the dismantling of the overhead equipment because the employees would be working above the auger. Other involved workers had apparently not applied separate, additional locks. The foreman left the rendering room to work on another project in a different area of the plant when the dismantling was completed and after instructing the workers to clean up metal debris. On his way out he had removed his lock and activated the main breaker for the circuit serving the auger, which was located in an adjoining room. The foreman did not expect anyone would be in or near the auger but could not see the auger or observe workers in the rendering room when he removed his lock. If seldom used, the auger wall switch would be left in the “on” position explaining why the auger started when the lockout was removed and circuit breaker closed.

It is not clear how the victim got to the location along the auger where he was entangled. Most likely he walked or climbed up its incline scouting for the bolt and other metal debris. There was no ladder in the area at the time of the incident. The auger was large and rapidly pulled his legs upward, entangling and traumatically severing them both at mid-thigh.

The incident occurred at about 3:00 PM. Emergency medical services were called and arrived within 10 minutes of the incident, just 5 minutes after receiving the call. The victim was awake and aware of his surroundings. Paramedics placed him on oxygen and initiated an intravenous line, the victim rapidly lost consciousness, stopped breathing and became pulseless. He was pronounced dead at the scene 45 minutes after the incident.
Cause of Death
The autopsy described the cause of death as “hemorrhagic shock due to traumatic amputation of the legs”.
Recommendations/Discussion
Recommendation #1: Equipment lockout/ tagout procedures must be fully implemented, including checking the work area to ensure that all employees have been safely positioned or removed before removing lockout and notifying employees that lockout devices have been removed from energy sources.