Near-Miss to Case Study: Learning from Close Calls Before They Cost Fatality File

US Department of Labor finds Encore Industries failed to use machine safety procedures leading to fatal injuries of production manager

What Happened

On November 17, 2021, a production manager at Encore Industries Inc. in Cambridge, Ohio was fatally crushed while clearing a jam in a thermoforming machine. As he worked, the machine’s conveyor cycled automatically and he became trapped. Two similar incidents had already occurred on the exact same machine — one on the day of the fatality and another just two days prior. In both cases, workers barely escaped injury. Neither near-miss resulted in any corrective action.

What Went Wrong

OSHA found the company knew machine components continued to move after the enclosure door was opened but allowed servicing to continue without adequate energy control procedures. The same lockout/tagout violations had been cited at the same facility in 2020. OSHA issued one willful, one repeat, and five serious citations, with $291,086 in proposed penalties.

The Bottom Line

“The company ignored reports of malfunctioning equipment and near misses,” said OSHA Area Director Larry M. Johnson. Two close calls on the same machine in the same week were not treated as warnings — they were the warning. When near-misses go unaddressed, the next event is not a close call. It is a fatality.

Source: https://www.dol.gov/