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Task-Change Transition: Whenever a Job Step Changes, Hazards Change Fatality File

Federal investigators cite Butler County, Pennsylvania, company for exposing workers to hazards after employee suffers fatal injuries

What Happened

On September 6, 2023, a worker at Vorteq Coil Finishers LLC in Valencia, Pennsylvania was fatally pulled into a running coater machine after being instructed to clean a chrome roller while the machine was still in operation. No one stopped to assess the hazards the new task introduced before work began.

What Went Wrong

OSHA found that management knew cleaning the machine while running was dangerous but required it to avoid downtime. No lockout/tagout procedures were applied, and no machine guarding was in place. OSHA issued two willful and two serious citations, proposed $345,685 in penalties, and placed the company in its Severe Violator Enforcement Program.

The Bottom Line

A worker was given a new task and sent directly into a known kill zone to perform it. Every time a job step changes, the hazards change with it — and that requires a stop, a reassessment, and the right controls before anyone proceeds. Skipping that step to save production time cost a worker his life.

Source: https://www.osha.gov/