1. The Case of the Jammed Machine
P O W E R P O I N T ® T R A I N I N G
Target Audience: This training session is intended for regular machinery operators or those who may occasionally work on machinery.
Learning Objectives: The focus in this session is specifically on teaching affected employees how to clear a jammed machine. This session can be used to reinforce points made in a full Lockout/Tagout (LOTO) training session or it can be used as refresher training. It is recommended that additional training be given on the hazards associated with LOTO.
Background for the Trainer:
This session presents a case study of an actual accident inspected and documented by the Occupational Safety and Health Administration (OSHA). The case presented in this training session is:
Accident : Employee’s Fingers Amputated in Pleating/Shearing Machine
Report ID:
Inspection:
You may choose to present this training information in a lecture format, or make the training presentation interactive by engaging your class in discussions that will help them identify facts of the case, potential causes of the accident, and future accident prevention measures. In either case, students will benefit by learning from a real-life scenario.
Print and make copies of the one-page Case Study Student Handout, which is provided on the disc. The Case Study Student Handout can be used as a worksheet during the training session or as a take-away reminder once the training session is complete.
Print and make copies of the Case Study Quiz, which is provided on the disc as a fully customizable document. The students can take the quiz at the end of the training session to help reinforce the information presented. Note that the same quiz is included at the end of this PowerPoint presentation.
If lockout/tagout is required in your facility, consider taking pictures of your own equipment when it is locked out. You can add these pictures to the presentation by inserting them into existing slides or creating new slides.
Be sure your trainees understand the material being presented by asking for questions or periodically testing understanding throughout the session.
Speaker’s Notes:
Welcome everyone. Today we will review a Case Study of an actual accident investigated by OSHA. This is an actual tragic workplace accident that had real-life implications for the worker, the worker’s family, co-workers, and the employer. The Case Study may be disturbing and may even involve a fatality.
This training session will reinforce the importance of lockout/tagout procedures in our workplace to help prevent tragic accidents. The specific focus will be on proper procedures for clearing jammed machines.
Lockout/Tagout—
The Case of the Jammed Machine
©2003

2. Let’s Look at the Stats
Each year, thousands of injuries occur during machine operation. Injuries include:
Cuts
Punctures
Fractures
Crushed limbs
Amputations
Muscle strains and sprains
Sight and hearing injuries
Burns
Electrical shock
Death
Speaker’s Notes
Each year, thousands of workers are injured on the job by accidents involving machinery.
Injuries that can occur range anywhere from cuts and punctures to amputations and even death.
These injuries are generally the result of not using proper machine operating procedures—including following specific lockout/tagout rules.

3. Take a Look at the Facts
Employee #1 operates a pleating/shearing machine
The machine jams
Background for the Trainer:
Training Option: Pass out the Case Study Student Handout. You may have the students read the accident description to themselves before discussing it in the class, or you may use the bullet points on the slide and the speaker’s notes below to describe the accident.
Speaker’s Notes:
Employee #1, a 42-year-old male, is operating a pleating/shearing machine, which is used to make, pleat, and then cut filter media.
The pleating/shearing machine becomes jammed with filter media.

4. Take a Look at the Facts (cont.)
Workers remove guard and open side of machine
Workers reach into shearing section to free jammed material
Speaker’s Notes:
A co-worker, Employee #2, opens the side of the machine in order to gain access to the filter media.
The co-worker attempts to clear the jam by pulling the filter media through the machine.
Employee #1 also reaches into the machine in an attempt to pull the material through and release the jam. Employee #1 is reaching into the shear section, or point of operation, of the machine.

5. Take a Look at the Facts (cont.)
Electric eye is triggered
The shearing ram is activated
3 fingers amputated on left hand of Employee #1
Speaker’s Notes:
An electric eye on the machine, which activates the shearing ram to cut, is triggered. How the electric eye was triggered is not known. It could have been triggered by an employee’s arm or hand, or even by the material itself as the employees pulled on it.
The shearing ram activates and drops a blade that is designed to cut the filter media.
The shear amputates three fingers down to the second knuckle on Employee #1’s left hand.

6. What Do You Think Went Wrong?
Do you think the workers acted properly to clear the jam?
Were safety procedures followed?
Did lockout/tagout play a role in the accident?
Were safety guards used?
What is so dangerous about a machine’s “point of operation”?
Background for the Trainer:
Use the questions on this slide to elicit discussion.
Training options: After reviewing this slide and the accident description, give the class 5 to 10 minutes to discuss the accident in small groups, or ask the students to try to determine some of the facts, potential causes, and possible prevention measures. In either case, use the Case Study Student Handout as a way of encouraging discussion as you go through this presentation.
Speaker’s Notes:
Consider some of these questions when discussing the Case Study in your groups.
Let’s take a few minutes and, using the Case Study Student Handout, work in groups to try to determine the facts of the accident, potential causes of the accident, and possible prevention measures. Then we will review the Case Study together in class.

7. Let’s Review the Causes
The machine was not locked out
Lockout procedures either not in place or not followed
Employees bypassed guards
Machine guarding not adequate
Employee reached into point of operation
Background for the Trainer:
Try to get trainees to put themselves in the place of the person in the Case Study. What would they have done in this case? Point out how a near miss can turn into a catastrophe in the presence of emergencies, sudden changes, fatigue, and poor judgment. In this case, the worker was attempting to fix the machine so she could continue working—but that decision turned into a bad call.
Speaker’s Notes:
The operators did not lockout the energy sources on the pleating/shearing machine before opening the guards and entering the machine’s danger zones. Before removing guards on any machinery, the energy sources on that machine must be properly locked out.
There may be underlying reasons why these workers did not apply lockout/tagout procedures to the machine. Maybe the employer did not have written lockout/tagout procedures as required by OSHA. Maybe the employees did not receive lockout/tagout training. Or maybe the employer did not provide easy access to locks and other equipment needed for lockout.
Employees bypassed safety guards by opening the sides of the machine so they could access the filter media. Remember, you should NEVER put yourself in danger by exposing your body to moving machinery parts, including the point of operation.
There may be underlying reasons why the employees bypassed the guards. Maybe the machine guards were not adequate and employees could easily reach into the point of operation without removing the guards. Maybe employees are encouraged by supervisors to open the guards in order to clear jams due to production pressures.
Finally, the injured employee reached into the point of operation, where the shearing or cutting action occurred, in order to grab and pull on the filter media.
Can you think of any other causes that may have contributed to this accident?

8. If You’re NOT Authorized
NEVER attempt to fix or maintain machinery
Notify a supervisor or someone in charge
Never reach around or remove a guard
Background for the Trainer:
Bring your company’s written lockout/tagout procedures for employees to review or discuss.
Note that this slide addresses the procedures that nonauthorized employees should follow if they encounter a jammed machine.
Speaker’s Notes:
OSHA requires that only “authorized” personnel can perform lockout/tagout on a machine. Authorized personnel receive specific training on how to lock out specific machinery. Authorized personnel must be trained annually, certified that they understand lockout procedures (i.e., written test), and audited at least annually to ensure that they still know how to properly lock out their designated equipment.
If you encounter a machine that needs maintenance or repair, notify the shift supervisor or the person in charge of maintenance at your facility.
NEVER reach around a guard or try to remove a guard in an attempt to fix a machine.

9. If You ARE Authorized Notify nearby workers and shut down machine
Isolate energy sources and apply locks
Place keys in your pocket
Test operating controls
Perform service or repair
Notify nearby employees before removing locks
Speaker’s Notes:
Before locking out a machine, the authorized employee will notify nearby workers that the machine is going to be locked out for service or repair. Other employees must be trained to stay clear of a machine when it is locked out. They are never to tamper with a lock or attempt to start a machine that is locked out.
Isolate the machine’s energy sources and then apply locks so they cannot be re-energized. This might include applying locks to control boxes, circuit breakers, valves, electrical plugs, compressed air controls, hydraulic controls, etc.
Once all the energy sources are locked out, be sure to place the keys to the locks in your pocket so they are under your control at all times. Do not leave keys in the locks or on top of the equipment where someone else could unlock the machine and start it up without knowing that you are still in the danger zone.
Test all the controls of the machine to make sure all sources of energy have been isolated.
Perform the work that required you to apply lockout—clear a machine jam, service the machine, change tools or cutting devices, etc.
Before removing locks, notify workers in the area that the machine will soon be re-energized and re-started. Make sure all of your tools have been cleared from the area. Install all guards and other protective devices. Keep all people at a safe distance. Remove locks in the reverse order that they were applied and then start up the machine.

10. Don’t Let it Happen to You
Do not attempt to fix any machinery without locking/tagging out
Never open machine guarding
Never bypass interlocked guards
Wear appropriate PPE
Use tools or other equipment to reach into point of operation
Background for the Trainer:
Bring any written procedures your company has for clearing jammed machinery.
Show pictures of or physically go to machinery requiring lockout/tagout in your facility.
Speaker’s Notes:
The natural tendency, or instinctive reaction, for many machine operators is to reach into a machine when it is jammed. An operator may even have cleared jams a thousand times without locking out or being hurt; however, this unsafe habit will eventually result in an injury.
Before clearing a jammed machine, turn off the power and follow your company’s lockout/tagout procedures. Make sure any stored energy is dissipated, such as air pressure, hydraulic pressure, mechanical springs, etc.
Remember, do not touch the machine unless you are trained and authorized to perform lockout/tagout on that machine.
Never reach around a guard or attempt to bypass an interlocked guard. Never remove guards and protective devices to access the machine unless the machine is first properly locked out.
Wear appropriate personal protective equipment (PPE). At times you may be clearing jams away from hot equipment, sharp blades, metal chips, and any number of hazards—depending on your operation. Wear equipment that is designed to protect you from those hazards. For example, wear cut-resistant gloves when near blades, leather gloves when exposed to metal chips, and heat protective gloves when near hot equipment.
Use tools or other devices necessary to remove jams. Instead of reaching into the point of operation, use a tool to reach into the point of operation—even when the machine is locked out. Keep your hands away from hazards whenever possible.

11. Quiz 1. Before removing a machine guard, what must be done?
2. Name at least two sources of machine energy that require isolation and lockout.
3. Any machine operator can lock out his or her machine. True or False
4. Where do you put the keys for the locks after locking out a machine?
Background for the Trainer:
Remind employees that the quiz is to encourage further discussion and to help you, the trainer, be sure that everyone understands what was discussed.
Print copies of the quiz for participants to take on their own, or go over the questions as part of the training session.

12. Quiz (cont.)
5. What can an operator use to avoid putting his or her hand into the point of operation?
6. Name two things that could have been done to prevent this accident.
7. What should be done after applying locks, but before entering the machine?
8. If regular access to a machine is needed, install an interlocked guard. True or False

13. Quiz Answers 1. Q. Before removing a machine guard, what must be done?
A. Lock out the machine
2. Q. Name at least two sources of energy for a machine that require isolation and lockout.
A. Electricity, compressed air, hydraulics, gravity, mechanical springs, steam, chemicals

14. Quiz Answers (cont.)
3. Q. Any machine operator can lock out his or her machine. True or False
A. False, only “authorized” personnel that meet OSHA’s training requirements can lock out a machine.
4. Q. Where do you put the keys for the locks after locking out a machine?
A. Put the keys in your pocket.

15. Quiz Answers (cont.)
5. Q. What can an operator use to avoid putting his or her hand into the point of operation?
A. Use a long-handled tool to keep hands clear.
6. Q. Name two things that could have been done to prevent this accident.
A. Lock out the machine, install guards that are not easily removed, use a tool to reach into the point of operation.

16. Quiz Answers (cont.)
7. Q. What should be done after applying locks, but before entering the machine?
A. Test the machine controls to ensure all energy sources are controlled.
8. Q. If regular access to a machine is needed, install an interlocked guard. True or False
A. True, the interlocked guard must shut down power to the machine when opened.