The circumstances were:
- Miroslaw Grzybowski was working on a production line to heat-treat carbon fibres where the material is pulled through a series of ovens operating at increasing temperatures.
- Despite suitable guarding being installed on similar trapping points on other production lines, SGL had failed to identify the risk on the line Mr Grzybowski worked on.
- The company also failed to identify the risk to employees of being in very close proximity to the machine during the recovery activity.
- SGL failed to ensure that when unclogging the process, movement of dangerous parts stopped before workers entered into the danger zone.
- On 13 February 2011 carbon fibre material coming out of an oven had wrapped around a roller.
- Mr Grzybowski and his deputy team leader went to the front of the oven, which was heated to 200C, and Mr Grzybowski climbed through the barrier and began to move the material that had caught using his left hand.
- He was wearing company-provided gloves and safety jumper but was not wearing the Kevlar arm sleeves provided by SGL.
- The deputy team leader, unaware that Mr Grzybowski still had his hand inside the machine, instructed another operator to open the nip roller, which narrowed the gap between two rollers trapping Mr Grzybowski’s left wrist.
- He reached in with his right hand to withdraw his left and burned that wrist too.
- Mr Grzybowski was taken to hospital with severe burns to the back of both his wrists and a first degree burn to the inside of his right forearm. The following week he underwent surgery to have skin grafts on his wrists and spent a week in hospital before returning to work with the company.
“This incident was entirely foreseeable and therefore entirely preventable. Where an employee is able to gain access to dangerous moving parts, there is a risk of coming into contact with them. SGL Carbon Fibers Ltd should have identified the risk posed to workers on this particular production line and made sure it was adequately guarded as they had done on other lines. Suitable guarding coupled with adequate information, instruction and supervision would have played a large part in avoiding this incident. The injuries suffered by Mr Grzybowski were further compounded by the high temperature of the roller.”