After a Fatal Accident, New Safety Standards [Lathe]

Yale Alumni Magazine ^ | November 2011 | Carole Bass

[Third Person]

The lathe that killed Yale student Michele Dufault ’11 last April, which had no guards and no emergency stop button, would not pass muster under the university’s strict new safety rules. And the shop where Dufault died alone—which, under the new rules, is deemed one of the most hazardous on campus—is no longer accessible to undergraduates without a faculty or staff supervisor.

Those are two of the most significant changes under the new safety standards, which Yale put in place this summer in the wake of Dufault’s death. The 22-year-old physics and astronomy major from Scituate, Massachusetts, was asphyxiated after her hair caught in a lathe in a Sterling Chemistry Laboratory machine shop, where she was working by herself in violation of the existing safety rules.

In response, Yale conducted a sweeping safety review of student tool shops. In addition to tightening shop access, the university replaced dozens of large power tools—including the lathe that killed Dufault—and upgraded scores of other tools.

Dufault went to the machine shop on the evening of April 12 to work on her senior project. Around 2:30 a.m. on April 13, other students entered the shop and found lights on and music playing. They discovered Dufault with her ponytail caught in a rotating part of the lathe, her body “compressed against the machine,” in the words of Robert Kowalski, area director for the federal Occupational Safety and Health Administration (OSHA).

The 77-page file from OSHA’s investigation of the incident, released to the Yale Alumni Magazine under the Freedom of Information Act, includes an extensive narrative based on a physical inspection, interviews, and other research. In a letter to Yale, Kowalski cites hazards he considers violations of federal or industry safety standards. The rules have changed over the years—becoming stricter in some cases and laxer in others—so compliance with industry standards in the case of an older machine like the lathe can be a matter of interpretation. Yale contends that the machine shop complied with all standards. (Because Dufault was not an employee, OSHA lacks jurisdiction to issue citations.)

Yale’s new rules divide the 28 facilities where undergraduates have access to power tools into five categories based on hazard level, taking “the existing best practices from several shops” and applying them across the board, says Steven Girvin, a deputy provost and physicist who led the review.

“The most significant aspect of the new rules is their uniformity and applicability to every shop,” Girvin wrote in an e-mail. “Many shops have additional rules that are specific to their operations.”

The changes address two “what-ifs” raised by the investigation: could Dufault have survived if the lathe had had an emergency shutoff? Or if she hadn’t been working alone? The 49-year-old lathe Dufault was using is nearly seven feet long, and had an off button 15 inches from one end—four to five feet from where she was working when the accident happened, according to a safety consultant’s report commissioned by Yale and included in the OSHA file. (The lathe could also be shut off with a lever, a Yale spokesman says. But that lever was still farther away.) Some newer lathes have larger, more centrally located emergency stop buttons, Kowalski says. Whether Yale was required to retrofit its lathe with emergency stops is a gray area. And without knowing exactly what happened that night, he adds, it’s impossible to know whether an emergency stop button would have saved Dufault’s life. Yale’s new safety standards require that all appropriate tools have the larger, easily accessible emergency stops.

As for working alone, Dufault had completed a 13-week training course, required before using the shop, and was nearly finished with a more advanced course. Calling the training “exemplary,” Yale’s consultant stated: “Ms. Dufault was well versed in both lathe operation and safety. Notwithstanding this training, she appeared to be working by herself”—contrary to the rule Yale had in place.

It’s harder now for students to break that rule. Instead of the self-policing buddy system, a new electronic access system physically bars undergraduates from the most hazardous shops unless a professional supervisor lets them in.

[Third Person]

Here is a link to the original story:

http://www.nhregister.com/articles/2011/04/13/news/doc4da58c22c4b1f135149346.txt?viewmode=default

[al baby]

Very sad. Very avoidable

[Paved Paradise]

Long hair is a hazard in itself, as are men’s ties, long scarves, and even wedding rings, depending on one’s occupation. I still remember when I was a child and those winter scarves that were a few feet long were all the rage until some kid was strangled by one...I believe on an escalator. The year was probably 1965 or 66. Those disappeared faster than you could shake the snow from your hat.

[Deaf Smith]

"Calling the training “exemplary,” Yale’s consultant stated: “Ms. Dufault was well versed in both lathe operation and safety."

Except when no one is there to boss her around about tying up her hair.

[Third Person]

Let's try the linky again:

here is the link to the original article.

[E. Pluribus Unum]

So, when somebody gets themselves killed because they didn't follow the rules, the solution is to add more rules?

What does that change?

Other than making it harder for the people who followed the old rules?

[Tallguy]

My grandfather had a shirt ripped off his back by a lathe. Back in the day shirts didn’t ‘give’ so easily. He was a bull of a guy but claimed he was bruised all over from bracing himself until the shirt parted.

[Whitebread]

Who knew you could take shop class at Yale?

[JRandomFreeper]

Long hair is a hazard in itself,

It is. I have a ponytail and before using my lathe or drill press or any rotating equipment, I put my hair up into a tight bun so things like this don't happen to me.

I'll be donating my hair in spring, so I can go back to the 1/4" buzz cut and not worry about it.

/johnny

[IAMIUBU]

My hair is to my waist. I use power tools almost every day, as I have since the age of 5 some 60 years ago. I’m very sorry to hear of this young persons death. The FIRST thing I told my 20 something assistant a few years ago was ‘a power tool and long hair, hers was longer than mine, is a dangerous combination. Always be aware.’

[Ruy Dias de Bivar]

I have worked alone with lathes (metal and wood), other power tools and milling machines for years. This appears to be a simple failure to take safety precautions like no loose sleeves, ties, or pony tails.

It is almost impossible to design a safety guard for lathes. You just have to be extra careful.

[coloradan]

When one person is killed by one lathe, the nation mobilizes to ensure it can never happen again. Now, how many innocent people have been killed in no-knock wrong-address raids, all of which were deemed “good shoots” by their respective departments?

[SteelTrap]

I remember my Dad teaching me how to work safely around farm equipment. After he told me a story about a guy who got killed by getting caught in a running PTO shaft, I made it a point to always avoid anything that spins. Well except for hot ballerinas, that would be safe.

[Redbob]

You don’t put “guards” on an experimental lathe; you keep your hair out of it. You keep your long clothing out of it. You keep your shoelaces out of it.
In point of fact, you try to train people not to behave in an unsafe manner around it, and those who are untrainable should be kept away from it.

Or else Darwinian selection will rear its ugly head.

[familyop]

After all of those decades, our bosses find it necessary to go far beyond the machine safety modifications requested by us. I wonder why...not.

No loose ponytails. That’s a very old and good rule for lathe operators.

[rottndog]

A manual metal lathe located in the Bray Laboratory Building machine shop is similar to the machine that killed Yale senior Michele Dufault on April 12.


The ONLY conceivable safety device that may have prevented this death is not on these lathes....a foot brake. I don't believe Michele, once she was caught in the spindle, could possibly have had the presence of mind to blindly hit the E-stop or reach the on/off lever and shut it off. A foot brake, however, extends the length of the bed of the lathe and not only turns off the spindle, but stops it almost instantly.

That being said, there is nothing that can make a manual lathe any less dangerous outside of good safety training, and an operator who strictly follows those safety rules. One of the most basic safety rules concerning the operation of ANY rotating equipment is to not work around it with anything attached to you...clothing, jewelry, HAIR....that can be caught and pull you in. In the Navy we were constantly reminded that most safety rules were written in blood. Something tells me Yale was deficient in getting that point across.

[reg45]

Obviously, the lathe already had a “kill” switch.

[dfwgator]

No loose ponytails. That’s a very old and good rule for lathe operators.

[NVDave]

Yep, that’s what I was thinking too - a foot brake on a gearhead machine might have done something. The e-stop... even on the carriage... I dunno..

Small bit of reference: The lathes pictured have foot brakes (the red treadle in the bottom center of the machine).

According to Yale and the OSHA report, the lathe in question was a 1962 Clausing. The OSHA report references a “Harrison-Claussing” but that’s nonsense. Clausing was making lathes in 1962 under either the name Clausing or Atlas. Harrison is simply the English outfit that bought up the remains of Atlas/Clausing later in the 70’s. I’m going to go out on a limb and say that the lathe was likely a Clausing, and OSHA is simply pointing at the company that carries parts under the name ‘Clausing’ today, which is Harrison-Clausing, part of the “600 Group” out of the UK that puts UK/US names on Chinese pig iron and calls it a “precision machine.” But don’t get me started on crap machinery that comes out of China or we’ll be here all week.

1962 Clausings, to my knowledge (and I’ve only looked at a few early vintage Clausings - 6300, 5300, 5400 and 4900 series machines) weren’t equipped with either an e-stop or a spindle brake. They were old-fashioned belt-drive machines, like the older South Bend or Sheldon machines.

The OSHA report said that her hair became wrapped around the lead screw, not the workpiece. For people who are not familiar with lathes, on rottndog’s picture here, look at the front of the lathe: You will see a red knob about the middle of the machine, just to the right of the carriage. Look above that, the dark shaft that runs horizontally the length of the bed. That’s the leadscrew on a lathe, it drives the carriage automatically when feeding or threading on a lathe. The leadscrew rarely turns all that fast, and doesn’t have but a fraction of the horsepower available to the workpiece, but it is still enough to pull someone in.

Now, for the people here who haven’t operated lathes: The lathes that rottndog just pictured there are actually fairly small machines, but are probably not that much different in size than anything you’d see in a school lab environment. Those look like 13x40 machines, ie, an ability to turn a 13” diameter workpiece up to 40” long. That’s not a very large lathe at all. As rottndog says, nothing can take the place of training and awareness by the operator. No amount of safety guards can make rotating machinery safe.