Press Crush (KV100)


What Happened?

At 12:00 p.m. on March 3, 2017, an employee was using a brake press to crimp a bar of metal to be applied to the end of a print blanket (cloth-like material used in printing operations). During operation of the press, one of his fingers was crushed resulting in its amputation.

Contributing Factors

Additional engineering controls could have prevented this from happening. The installation of light currents or other forms of Poke Yoke could have helped physically remove the employee from the harmful environment.  

What Can We Learn?


The employee could have prevented this situation by using a Questioning Attitude about the hazards present.

A Self Check at the start of the shift could have helped him identify the safety concern and increased error likely situation of the press.


Self-imposed Time Pressure was relevant in this situation. The employee did not allow for a sufficient amount of time to remove his hands from a crush point.  

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?