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Ms. Frias was working at Bimbo Bakery tending a
mass-production high-speed bread-dough proofing machine. One of the rolls of dough partially fell from
its proofing tray on the conveyor within the dough-proofing machine. To prevent the fallen dough from interfering
with production, Ms. Frias reached into the machine to remove it. Her arm was caught by the cogs & chains
that motivated the conveyor and severed from her body.
We performed an investigation that showed the machine had
been altered by the bakery to operate at approximately twice its design
speed. This caused the dough to
partially fall from its proofing trays regularly. Instead of stopping the entire production
line in order to safely remove the partially fallen dough when it occurred, the
bakery responded to this recurring situation by removing the permanently
affixed side panels of the machine and instructing its worker to reach into the
moving machine to remove the partially fallen dough.
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