Shepherd Neame was fined £11,000 after employee loses finger in poorly guarded machine

Brewer Shepherd Neame was fined £11,000 (inc. costs) on 29 January 2015 after a 21 year-old agency worker lost a finger in an unprotected machine.

The circumstances were:

• Equipment was inside an enclosure mostly protected with interlocks and lightguards.
• However, there was one gate which had no such interlock.
• This gate had been only sporadically secured since it had been installed. 
• It had been seen to be open during an inspection by HSE in 2012, at which time the company agreed to lock and secure the gate as soon as the line became operational again following repair work. 
• However, the accident shows that this was not done.
• On 23 June 2014, an employee entered this fenced-off section with the machine still running.
• He was hosing down an area when he slipped.
• His left arm instinctively shot out as he tried to regain his balance, but his hand came into contact with one of the operating parts of the machine. 
• It immediately began to be drawn in by a sprocket at the end of a conveyor.
• Realising what was happening, he pulled his arm back but when he managed to free his hand, he realised he had lost the top part of his index finger and crushed his thumb and middle finger.
• As a result of the incident he needed a full amputation of the left finger and repairs to his thumb and middle finger. 
• He has been unable to return to work 

The HSE Inspector said:

“This was an entirely-preventable incident. Shepherd Neame was aware of the guarding requirements for such a machine, but neglected to make sure that these safety measures were fully and consistently implemented. Those failures led to an employee suffering a painful injury that has permanent consequences.  Shepherd Neame had received previous advice from HSE on the same issue, but didn’t act sufficiently robustly to prevent this type of incident happening. All employers have a duty to protect their staff from risks they face doing their work and, in this case, that means making sure running machinery is effectively guarded.”

2 companies fined a total of over £32,000 after employee was injured by unsafe use of a forklift truck

New Earth Solutions Group Ltd, was fined £15,241 (inc. costs) and NEAT Technology Group Ltd fined £17,241 (inc. costs) after an employee was injured during an unsafe operation using a forklift truck. Both companies are based at the same address in Verwood, Dorset.

The circumstances were:

• New Earth Solutions Group Ltd, which runs a mechanical biological treatment facility at Avonmouth, had commissioned an energy recovery facility next to the site.
• During the design, build and commissioning phases, the new facility was under the control of NEAT Technology Group Ltd. 
• Neither company assessed the risks associated with unblocking vacuum filters 
• Nor did they identify a safe system of work using appropriate equipment to unblock the machine. 
• Both companies also failed to sufficiently train and instruct workers to unblock the filters safely and did not monitor or supervise the process.
• An employee was tasked with helping empty ash, a by-product of the thermal treatment process, from steel barrels using a specialist vacuum machine.
• During the process, one of his colleagues used a fork lift truck to shake the vacuum to dislodge any remaining ash deposits from the filters.
• It came off the forks of the truck, overturned and struck the cleaner, trapping him underneath.
• He suffered a fractured back and two fractured ribs, and was unable to return to work for seven months.

The HSE Inspector said:

“This incident highlights the importance of effectively controlling the risks associated with all work processes. This did not occur in this case, and the consequences could have been far more serious. This incident could have easily been avoided and the injured cleaner would not have been injured had both companies planned this work properly and provided with appropriate training and supervision.”

Unguarded woodworking router causes loss of finger

North Quay Trading Limited, a Kent joinery firm was fined on 27 January after an employee lost the tip of his left middle finger on an unguarded piece of machinery.

The circumstances were:

• An overhead router had a guard, but it had been removed during a change in tooling and not refitted.
• This happened at least a couple of weeks before the accident.
• A worker was the router to manually machine a rebate along the edge of some door panels. 
• As he worked on his third or fourth panel his left hand slipped and came into contact with the cutting tool.
• This required a partial amputation of the injured digit.

The HSE Inspector commented:

“The worker suffered a painful injury and is now permanently disfigured as a result of an incident that was entirely preventable had the safety guard been in place. Guards are there for a reason and the onus was on North Quay Trading Limited to instigate routine checks to ensure they were fitted and working effectively at all times. A substantial number of the injuries reported to HSE involve workers coming into contact with dangerous moving parts, particularly in a manufacturing environment. The risks are clear and safety guidance is freely available covering guarding requirements.”

Belvoir Associates fined £24,500 after serious hand injuries due to makeshift vacuum extraction.

Belvoir Associates Ltd., a Rutland company which manufactures children’s bedroom furniture, was fined £24,449 (inc. costs) after a machine operator suffered serious hand injuries in a makeshift vacuum cleaner.

The circumstances were:

• The company had modified a portable dust extraction system using pipes and connections to secure a long flexible hose to the extractor’s inlet.
• The system regularly became blocked with wooden off-cuts.
• The company failed to assess what risks the machine posed to those using it. 
• No training or information had been provided to employees.
• The person who was subsequently injured was unaware of the location of any rotating fan blades.
• On 4 April 2013, the portable dust extraction system had been used to clean down both wood processing machinery and the floor. 
• Eventually, it became blocked.
• Three operatives attempted to unblock it using two tried and tested methods, including the removal of an end cap. 
• When these failed one of them put his left hand into the opening, where the flexible and solid pipes joined, to try clear the blockage, but his hand was drawn directly into the blades of the machine.
• He suffered multiple finger fractures and dislocations and required a number of operations. He has undergone physiotherapy but has lost 40 per cent of the use of his hand and is not expected to regain full use of his fingers.
• He was off work for ten months but has returned to Belvoir Associates albeit in a different role as he no longer has the manual dexterity to undertake physical work.

The HSE inspector said:

“This incident was foreseeable and preventable. As soon as the unit was converted, several significant risks resulted. It was, in effect, a Heath Robinson arrangement of domestic pipe fittings, flexible hoses and duct tape, none of which constituted the provision of fixed guards. The use of domestic pipe fittings created an obvious place for blockages to occur and using the machine to vacuum not only wood dust but also solid wood waste and off-cuts, as well as general debris from the floor, increased the risk of blockage considerably. Belvoir Associates failed to see any of the potential dangers arising from the new use of the unit because it neglected to properly judge the risks. It also failed to act once it became aware of the blockages in the machinery and instead left individual operators to unblock the unit resulting in the development of unsafe methods.”

Worker loses arm in circular saw which was still running down

Stagecraft Display Ltd, of Llandrindod Wells, was fined  £21,865 (inc. costs) after a woodworker had his right arm severed while clearing sawdust from underneath a circular saw.

The circumstances were:

• Although the machine was fitted with an interlock that stops power to the saw when the door to the saw well is opened, the saw took more than 30 seconds to stop completely.
• A self-employed machine maintenance engineer inspected the saw three months before the incident and told one of the company’s managers that it should be taken out of service or fitted with a brake which would stop the blade much sooner.
• On 23 February 2012, Brian Morris had finished sawing for the day and his last task was to clean the saw and saw well.
• He stopped the machine and opened the door of the well while the blade was still running down and was on one knee blowing air into the well to clear the dust. 
• At the same time a forklift truck drove into the factory and he turned his head to look.
• As he did so the moving blade caught the sleeve of his work jacket and cut his right arm. Although he managed to pull himself free, the arm was almost wholly severed.
• Mr Morris was taken to hospital, where he remained for a month, but doctors were unable to successfully reattach his arm and he underwent an amputation below the elbow.
• He was unable to return to work because of his injuries and has since died from an unrelated illness.

The HSE inspector said:

“This incident was entirely preventable. Saws cause the most injuries in the woodworking industry and power-operated circular saws are dangerous machines which have caused many serious incidents. Employees should not be able to gain access to dangerous parts of the machinery while they are moving and Stagecraft Display had a duty, as do all employers, to ensure that this cannot happen. Unfortunately in this case the saw had not finished rotating despite the fact that Mr Morris had switched it off and he then inadvertently came into contact with the moving blade, suffering a horrific injury.”

Crisp producer fined after worker lost part of finger in unguarded sprocket

Herefordshire crisp producer Tyrells was fined £13,000 (inc. costs) on 19 January 2015 after a worker lost part of a finger in the moving parts of a fryer.

The circumstances were:

• A chain and sprocket on a stirrer on a fryer was inadequately guarded.
• On 7 November 2012 an employee was cleaning the machine.7
• His finger caught in the nip point of the moving chain and sprocket.
• His middle finger on the left hand was severed just below the first joint.
• He was off work for two months but returned to work for the company. 
• A fixed guard was later fitted to the chain and sprocket.

The HSE Inspector said:

“The incident was entirely preventable. Tyrells Potato Crisps Ltd failed to ensure that moving parts capable of causing injury and within hand reach were adequately guarded.  Employers are required to take effective measures to prevent access to dangerous parts of machinery, or stop their movement before any part of a person enters a danger zone.”

Wye Valley Brewery fined £29,632 after worker was injured in a confined space

Wye Valley Brewery was fined £29,632 (inc. costs) on 20th January 2015 after a worker suffered a broken foot when it became trapped in a rotating stirrer.

The circumstances were:

• Wye Valley Brewery had advice about safe systems of work for confined spaces but ignored it.
• As a result there had been no risk assessments on entering confined spaces.
• There were no systems for controlling work in confined spaces or for isolating equipment.
• There was no emergency rescue procedure.
• On 20 February 2013 an employee entered a mash tun, which is a large steel vessel.
• The stirrer in this vessel was still running.
• His right foot became caught in the stirrer.
• He was rescued by colleagues and was off work for two days.
• He has since returned to work.

The HSE inspector said:

“Wye Valley Brewery had advice and information about devising safe systems of work for entry into confined spaces, but ignored it and failed to consider the risks to its employees. As a result, a man suffered a painful injury.  He was very fortunate that colleagues heard his cries for help and managed to rescue him in time.”

Aspenlink fined £14,700 after worker was crushed by reel of paper

Aspenlink, a Hertfordshire-based company was fined £14,700 (inc. costs) after a worker suffered multiple injuries when he was struck by a 3.2 tonne reel of paper.

The circumstances were:

• Aspenlink's safety consultants had, on three consecutive years from 2010, advised them of the need to carry out a proper risk assessment and introduce a safe system of work for loading paper reels.
• Aspenlink failed to act on this advice.
• On 25 September 2013 an employee was helping to load the reel onto a container. 
• He was actually in the container.
• He was hit by the reel after it was released by a forklift truck, trapping him between the reel and the bulkhead of the container.
• He sustained a double fracture to his pelvis, as well as internal injuries, remaining in hospital for almost a month. He has had to undergo a series of operations, and has only recently returned to work.

The HSE Inspector said:
“This was an entirely avoidable incident. The dangers associated with paper reels, in particular the risks associated with their loading and unloading, are well-known in the industry and entirely foreseeable. Aspenlink was first made aware of the numerous shortcomings in its management of health and safety by its own health and safety consultant in 2010 – some three years before the incident – but it failed to act on this advice. The company should have carried out proper assessment of the risks facing workers. Instead, it waited for an employee to be seriously injured before taking any action.”

SGL Carbon Fibers fined £10,000 after serious burns

SGL Carbon Fibers, a Highland manufacturing company was fined £10,000 after a worker suffered severe burns to both arms as he tried to clear a blockage in an unguarded machine.

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.

The HSE inspector said:
“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.”

JCB fined after employee was crushed

JC Bamford Excavators Ltd was fined £26,390 (inc. costs) after a worker was left with multiple injuries after being crushed during the assembly of a telescopic handler.

The circumstances were:

• There was a designated area of the assembly track where hydraulic fluids were pumped into the machine and steering and other systems operated to force the fluids through the system.
• The assembly sequence for the telescopic materials handler was changed, which led to the fitting of the front offside light and mirror arm being moved from a point when the hydraulics were not live, to a point when the hydraulics were live and functions such as steering were tested.
• On 3 June 2013 Roger Pearce was installing the vehicle’s offside light and mirror arm.
• This required him to crouch down.
• As a result of this, he could not be seen by a colleague testing the steering.
• When the steering was activated, he was crushed between a wheel and the bodywork.
• He fractured ten ribs; damaged the bones at the base of his spine, and injured his bladder and kidney. He was hospitalised for ten days and is still undergoing treatment. He has not been able to return to work.

The HSE inspector said:
“This was a serious incident with Mr Pearce sustaining injuries from which he has yet to recover. It was also a preventable incident. JCB had allowed the introduction of a serious hazard and failed to assess the risk from this change. The controls that were in place were inadequate and Mr Pearce suffered serious harm as a result. Since the incident, the fitting of the light and mirror arm has been moved back to earlier in the assembly sequence when the hydraulics are not operational. Other changes have included barriers around the assembly area and the introduction of a banksman to control personnel working within it. The risks associated with the manufacturing processes involving large pieces of powered equipment should be assessed to ensure that there are effective controls and safe work procedures to protect those involved in this work.”

Gardiners Colours fined after death caused by load falling from forklift truck

Gardiner Colours was fined £116,000 (inc. costs) after a worker died when he was crushed beneath a one tonne silo of varnish that slid from the tines of a forklift truck and toppled onto him.

The circumstances were:

• Gardiner Colours makes inks, varnishes and coatings.
• A customer had returned part of an order as it couldn’t decant varnish from a silo and had asked for the liquid be re-sent in 10kg plastic containers.
• Because of difficulties in changing the order, workers were tasked with decanting the varnish directly from the silo into the containers via a tap at the base of the silo, which had been raised on the tines of the forklift on 25 March 2011.
• Gardiner Colours failed to assess the risks to workers of the decanting operation. As a result, employees were operating without a system of work in place to help them do the job in safety.
• It is dangerous for the forklift to be used to balance heavy loads for extended periods – a job for which it was not designed.
• There had been previous near misses with a load falling from the tines of a forklift truck but not action had been taken.
• As Wayne Potts worked on the decanting, the silo slid down the tines and fell directly onto him. He died in hospital later the same night.
• A combination of the creeping heavy load, the downward tilt of the forks, and the valve being used frequently from below, had caused the silo to fall.

The HSE Inspector said:

“A system that involves a person standing in the immediate vicinity of a suspended load on a forklift truck, which had no driver, is inherently unsafe. The forklift is not capable of holding elevated loads for long periods yet it was a system that had been allowed to develop over time, despite there being readily-available, safe alternatives. Every worker should quite rightly expect that they will return home safely from work every day. Sadly this did not happen for Wayne Potts that day but there is no doubt that his death was avoidable had Gardiner Colours effectively managed the health, safety and welfare of its employees and learned lessons from previous incidents and near-misses.”