Incident Investigation Refresh: Making the Most of What Happened Fatality File
US Department of Labor finds Wisconsin worker’s fatal 2023 injuries occurred on machine 3M Company identified as hazardous in 2022
What Happened
In February 2022, a worker died at a 3M Company facility in Alexandria, Minnesota after becoming caught in powered rollers on a plastic extrusion line. Following that fatality, 3M conducted a corporate-wide review of equipment at its U.S. and Canadian plants in May 2022 and determined that powered rollers were hazards in need of safety improvements. The findings were documented. The corrective actions were identified. And then, in 2023, a worker at 3M’s Prairie du Chien, Wisconsin facility was helping set up a plastic extrusion line when they became caught in the same type of machine and died.
“The tragedy of another employee’s death in Wisconsin is compounded by the fact that the 3M Company completed a corporate-wide review and determined powered rollers were hazards in need of safety improvements,” said OSHA Regional Administrator Bill Donovan.
What Went Wrong
OSHA determined the 3M Company violated federal regulations for the control of hazardous energy during set-up, servicing, and operation of the machine. The investigation had been done. The hazard had been identified. The corrective actions had been recommended. What failed was the follow-through — the step that converts an investigation finding into an implemented, verified, and sustained fix. Without that final step, the investigation produced a report, not protection.
The Bottom Line
A worker died. The company investigated. The hazard was found and documented. Another worker died on the same type of machine. An incident investigation that ends with a finding and not a verified corrective action is not a completed investigation — it is an unfinished one. The most important question after any investigation is not “what did we find?” It is “what did we actually change, and how do we know it worked?”
Source: https://www.dol.gov/newsroom