Robotic platform kills carousel operator at Nebraska meat packing plant

What happened

The plant used a computer-controlled system to store and retrieve boxes of meat. Conveyors fed boxes to an inserter/extractor, whose platform moved up and down to place boxes into, or take them out of, a carousel. A light sensor near the end of each inbound conveyor told the system when a box was ready to be picked up.

According to the Nebraska FACE report, a coworker was repairing an outbound conveyor on an upper level in the early hours of June 8, 1999. He had shut off power to that conveyor, but power to the carousel and the inserter/extractor, whose shutoff was on the lower level, had not been locked out as the posted procedure required. The 23-year-old carousel operator went to the upper level to watch and stepped onto the adjacent inbound conveyor for a better view.

His foot interrupted the light beam. The system responded as if a box had arrived, and the platform came down, pinning him between the platform and the conveyor and striking his head. When coworkers raised the platform, he fell about 15 feet to the concrete floor. He was pronounced dead at the scene. The investigator concluded that the blow from the platform, rather than the fall, most likely caused his death.

The system involved

The report describes the equipment as a system referred to by the brand name Alvey, made up of conveyors, inserter/extractors and a carousel, all under computer control. The component that struck the worker is described as a robotic platform that is part of the inserter/extractor. It moved automatically in response to a light sensor and was not under direct human control at the time.

Investigation and response

The Nebraska Department of Labor was notified by OSHA on the morning of the incident. A state FACE investigator and an OSHA compliance officer visited the plant on June 8 and 9, interviewed managers and workers, and reviewed police reports.

The FACE report recommended that employers lock out and tag out all equipment before maintenance, consider spot inspections to check compliance, keep people who are not involved in maintenance out of the immediate area and consider a protective grate around access points to the robotic platform. The report notes the employer had a written safety program, a full-time safety manager and a record of enforcing its rules, and that earlier fatalities had occurred at the same location.

What is not established

The report does not name the company or the city, and it does not say whether OSHA issued citations.