1. The copyright to this material belongs to the Korea Occupational Safety and Health Agency. Unauthorized use and distribution are prohibited. If an individual uses this for non-commercial purposes, the Korea Occupational Safety and Health Agency must be cited as the source. A corporation using this material must obtain permission from the Korea Occupational Safety and Health Agency first. Using this material without prior permission will be considered copyright infringement, and legal action may be taken. Manufacture Crush between table and machine body while lubricating CNC (CNC - Crush ) 2009.05 -Serious Accidents in Manufacturing - 안전분야 - 교육자료 미디어개발 2009-73-449

2. Table of Contents I. Fatality Overview II. Process Overview III. Fatality Object IV. Fatality Process V. Fatality Cause VI. Precautions

3. Think it over! Find out the Hazard Points in the figure below.

4. I. Fatality Overview II. Process Overview III. Fatality Object IV. Fatality Process V. Fatality Cause VI. Precautions I.Fatality Overview Date & Time: 09:00, August O, OOOO Place: OOOO boring workplace in Busan Victim: a production worker While the victim lubricating tool carriage on boring CNC, He crushed between horizontally moving table and machine body to death.

5. II.Process Overview Process Overview (wardrobe door manufacturing process ) Working process –The working process was to bore holes to mount hinge using a CNC machine. –The boring CNC machine was composed of a tool carriage moving in vertical direction and a table to place materials in horizontal direction that was moving forward and backward. The machine was automatically controlled by a computer. Chamfering TaperBoring Pattern Color Shipping Raw Material Receipt Cutting I. Fatality Overview II. Process Overview III. Fatality Object IV. Fatality Process V. Fatality Cause VI. Precautions Fatality Process

6. III. Fatality Object Fatality Object –Fatality Object: boring CNC machine –Table: 2,000 ㎜ × 1,800 ㎜ –Dimension: 6,340 ㎜ × 6,900 ㎜ × 4,800 ㎜ –Weight: 37.2 ton I. Fatality Overview II. Process Overview III. Fatality Object IV. Fatality Process V. Fatality Cause VI. Precautions CNC Boring M/C

7. IV. Fatality Process August O, OOOO, the victim went to the site at about 08:30 and attended a morning meeting to receive a work order at about 08:40. At about 08:40, he was placing MDF plywood on the table to bore holes to mount hinges in front of the boring CNC machine. At about 08:50, the victim started the machine and was lubricating tool carriage standing between table and machine body. He crushed between the table and machine body to death. I. Fatality Overview II. Process Overview III. Fatality Object IV. Fatality Process V. Fatality Cause VI. Precautions reconstruction (lubricating) position at the time of fatality

8. IV. Fatality Process CNC machine ’ s operating processes –Inputting working details into a program –Placing MDF plywood on the table –Operation –table moves to the body direction from its initial position and stops at the 1 st processing position –Hole processing after tool post lowering –Tool post raising –Table moves to the 2 nd processing position (forward to his body) –Hole processing after tool post lowering –Tool post raising –Table moves to the 3 rd processing position (forward to his body) –Hole processing after tool post lowering –Tool post raising –Table shifts (opposite direction of the body) –Tool post shifts (left direction from the front) I. Fatality Overview II. Process Overview III. Fatality Object IV. Fatality Process V. Fatality Cause VI. Precautions

9. V. Fatality Cause Machine was not stopped during maintenance, etc –To lubricate the carriage for smooth movement of tool post during wood processing of CNC machine, you must stop the operation. However, the maintenance was conducted during machine operation. –To lubricate the carriage during machine operation, lubricating must be automated or semi-automated to prevent workers from approaching any dangerous position. However, the worker was working too close to the carriage. Insufficient CNC protections –There was a crush hazard into stroke end during reciprocating motion of CNC machine table. However, there was no cover or fence at the site. I. Fatality Overview II. Process Overview III. Fatality Object IV. Fatality Process V. Fatality Cause VI. Precautions

10. Maintenance should be conducted after stopping a machine –Machine operation must be stopped for CNC service, cleaning, oiling, inspection, repair, or any other similar work. –Automation or semi-automation of luburicating method is necessary not to allow workers to approach any dangerous position. Thorough CNC protections –A safety fence must be installed at the end of the table stroke of CNC machine to prevent workers from approaching the machine. I. Fatality Overview II. Process Overview III. Fatality Object IV. Fatality Process V. Fatality Cause VI. Precautions

11. Thank You.