New York Fatality Assessment and Control Evaluation (NY FACE)


Not following lockout/tagout procedures can be fatal.

danger sign

A food production worker died after suffering a deep cut to his neck from a steel blade on a dough machine. On the day of the incident, the victim and a co-worker were assigned to clean the dough machine. The victim turned off the machine and locked the main power switch, but missed setting one of the three blade control switches to its lockout position. As the victim was cleaning a hopper above the blade, the co-worker asked him for his key to unlock the main power switch of the dough machine. The victim handed the key to the co-worker who turned on the machine. This caused the dough blade to go through its automatic cutting cycle, fatally injuring the victim. (Case Report: 02NY096)

How Can This Be Prevented?

  • Provide employee training to ensure workers understand lockout/tagout programs.
  • Conduct periodic inspections to endure lockout/tagout proceduress are followed.
  • Modify cleaning procedures to avoid placing workers' bodies into points of operation.
  • Install interlocks to eliminate possible human errors during machine maintenance and sanitation.

The New York Fatality Assessment and Control Evaluation (NY FACE) program, in cooperation with the National Institute for Occupational Safety and Health (NIOSH) is one of many workplace health and safety programs administered by the New York State Department of Health. Additional information about the NY FACE program can be obtained by contacting:

New York State Department of Health
Bureau of Occupational Health and Injury Prevention
Empire State Plaza-Corning Tower, Room 1336
Albany, New York 12237