Working amid the din of giant steel presses and shouting commands to a co-worker he couldn't see, 23-year-old Michael Oberley was struck in the head by the machine he was trying to fix.
No one is sure what happened.
No one saw the impact.
For five days, Oberley lay in Parkview Hospital on life support before his mother decided it was time to let go. Doctors had given her no hope.
Nearly two years later, Joyce Pranger can't bring herself to enter her only child's bedroom.
"Life was great. He could talk to anybody," she said of her son.
"He was just trying to move on with his life. He had a girlfriend. He wanted to maybe get married."
The Indiana Occupational Safety and Health Administration spent several days investigating Oberley's employer, AccuGear, and found two serious violations.
It fined AccuGear $3,750 and the Fort Wayne company made required changes.
Oberley's death in May 2011 is one of the more recent industrial fatalities in northeast Indiana. It and others come as workplace deaths, injuries and illnesses decline nationwide. OSHA laws are largely credited for the drop.
They also come as the Indiana OSHA inspects far fewer businesses than it did in the 1980s and '90s and as federal OSHA pushes to increase penalties to further lower the nearly 5,000 yearly workplace fatalities and nearly 3 million injuries and illnesses that still could be prevented.
Between 2000 and Oberley's death in 2011, there were 21 workplace fatalities in Allen County, according to federal OSHA data.
Formed in 2008, AccuGear was relatively new when Oberley died. The company reported eight injuries in 2009, five that required days away from work, according to IOSHA records. There were no injuries in 2010. There were three, including the fatality, in 2011. The two other 2011 injuries did not require time away from work.
That Oberley's death marked the first time IOSHA inspected AccuGear might not be surprising given the agency inspects only a fraction of Indiana businesses annually.
Pranger's tragic loss has left her frustrated that more isn't being done
"AccuGear should have been inspected way before this happened," Pranger said. "But if they don't have enough people to perform the inspections, then that's not going to happen. But, like the fines, yes, they were too low."
Oberley worked as a maintenance technician; it was his job to repair presses at AccuGear, a company of about 100 employees that manufactures gears and vehicle components at 6710 Innovation Blvd. He worked there about seven months.
Records of its investigation provided by IOSHA to The Journal Gazette, deleted some names but give this account of the May 19, 2011, accident:
About 11:30 a.m., the press operator and Oberley had been troubleshooting problems with a 750-ton press, a machine two stories high. The noise level, an IOSHA inspector found, was at 95 decibels, as loud as a subway train at 200 feet or a lawn mower, according to hearnet.com and other websites. The area required hearing protection.
The operator was at the control panel and Oberley, only a few feet away, was at a conveyor system on the machine. A large pedestal next to the control panel blocked their view of each other.
During the troubleshooting the operator had shouted "fire in the hole" several times, with Oberley responding "OK," according to the records. At one point, the operator thought he got a positive response from Oberley and started the machine. The control panel signaled a fault and Oberley was found on the floor, the left side of his head apparently struck by a metal 2-by-4 bar that glides in and out of the machine.
According to employee accounts, one co-worker performed CPR on Oberley, earplugs still in his ears. "As I was doing the CPR (deleted) and I were yelling to Mike that he was OK and to stay with us and that the EMS was on its way."
Oberley stopped breathing several times before emergency workers arrived.
An IOSHA inspector was told about 8:10 a.m. on May 25, 2011, that Oberley had been taken off life support during the night. A walk-around inspection at AccuGear – whose managers had become fixtures at the hospital, Pranger said – began that day. Many employees had gone home after learning Oberley died.
The IOSHA inspector visited the site eight days to complete the investigation. His report concluded that there was no protective guard in place, "to prevent an employee from being in the hazard area," when the machine was cycling. In addition, AccuGear did not have "procedures for communication between employees when there is no line of sight between them."
Both were serious violations, workplace hazards that would most likely result in death or serious physical harm, according to federal standards.
The protective guard violation was corrected during the IOSHA inspection. AccuGear reported to the agency in an Aug. 4, 2011, letter that it had modified its communication procedure to require "line of site positive control when complete isolation at equipment is not feasible."
Each violation carried a maximum $7,000 fine, under federal rules. AccuGear was fined $2,500 for each and received a 25 percent credit: 15 percent for its good faith efforts and 10 percent for its lack of a violation history, according to IOSHA records. So, each violation was adjusted down to $1,875.
On Aug. 12, 2011, the state received a $3,750 check from AccuGear's mother company, American Axle and Manufacturing in Detroit, to cover the fine.
Pranger and her husband, Michael Pranger, said they expected a larger penalty, maybe $50,000 or $100,000. But large fines, according to IOSHA officials, are levied when companies are cited for repeat or knowing violations. That wasn't the case at the relatively new AccuGear.
Robert E. Dittmer, spokesman for the Indiana Department of Labor, said the penalty reductions were mandatory and equating the fine to a lost life would be "totally inappropriate."
Other than to confirm that the company complied with IOSHA's required changes after Oberley's death, AccuGear spokesman David Tworek said the company had no comment.
Pranger said she was told by lawyers that she could not file a lawsuit against AccuGear under Indiana law. She thought bringing attention to the case might make the workplace safer, she said.
"I just wanted to do something but couldn't do a darn thing, they were telling me. It just killed me," she said.
Workers' compensation, which pays for workplace injuries and covered Oberley's hospitalization, is the exclusive remedy for employee claims and does not allow next of kin to sue an employer, said Mark S. Kittaka, a Fort Wayne lawyer who represents employers on state and national OSHA matters.
Kittaka said that is nearly universal among states.
Joyce Pranger, then, is left with her son's memory and her solace that he didn't suffer. Her doctor, who was then the county coroner, told her Mike didn't see it coming.
"I was glad and just hope it was quick," she said. "And to be hit that hard that fast I'd think it would be quick, because he never regained consciousness or anything."
- Search Indiana workplace inspections dating from 2000 to September 2011
IOSHA falling down on job?•Second in a two-part series on the state agency that regulates workplace safety