A Day In A Life

A Day In A Life
Tragedy can result when machine safety systems aren’t in place, or are overridden by employees.


It was 10:52 p.m. when Steven, a machine operator, was called to help clear a jam on the machine located next to his. When he looked at the machine, he realized almost immediately that the problem was a stacked stock.
Ivan, the operator of the jammed equipment, could not clear the machine. He left his personal reset key in the reset button keyhole and entered the code for the machine to start clearing the jam. However, it was unsuccessful.
The machine was protected by a light curtain and in order to get the machine moving, it had to be reset. He placed his both hands inside the knife area of the machine and was trying to pull the stock very hard, but it did not move. Ivan asked Steven to reset the light curtain by pushing the reset button and run the machine.
Just as the stock stated to move, Ivan immediately felt a strong pinch on both of his hands. Fingers on both of his hands were cut off by the machine. With all his might, he screamed for help, but it was too late. Eight of his fingers were on the floor and blood was pouring from his hands.
Ivan paid a huge price for this horrific accident. Even more unfortunate is that it was easily avoidable.
We had recently upgraded this machine and it had all the necessary protection, as stipulated by the current and applicable machine guarding standards and codes. I received a desperate phone call first thing the next morning; the client wanted us to be there right away. The provincial Ministry of Labour (MOL) had been notified and an inspector had arrived in the middle of the night, as well as the police. The machine was locked down for further investigation.
Our investigation began with an analysis of the accident.
These types of machines are notoriously difficult to effectively guard by using fixed guarding or continuously using lockout/tagout methods, because the operator must frequently interact with the equipment. The CSA Z-432 machine guarding standard does allow for exceptions to locking out equipment if it is integral to the process and routine.
When lockout/tagout isn’t practical, the standard allows taking the energy sources out of the equation. Installing a light-curtain protective system and personalized reset key keeps employees from coming in contact with energy sources during routine operating processes, such as clearing jams and doing minor maintenance. This type of protection is very effective, if the employer and employees fully understand its use and, more importantly, its limitations.
The investigation revealed that the light curtain protective system met all the requirements stipulated by the machine guarding standard.
Later the same morning, the MOL engineer arrived. He checked the Pre-start Health and Safety Review report (known as a PSR). The report included a hazard analysis, which identified the quality of the safety system based on frequency of exposure, severity of harm and possibility of avoidance. The hazard analysis established the degree of redundancies necessary for the system, based upon the degree of exposure. The standard specifies that the higher the degree of exposure to harm, the greater the degree of redundancies. In this particular situation, the system was rated control reliable or dual channel with monitoring.
The MOL engineer also checked the schematics of the system and verified that the system met the requirements for a control reliable system.
The conclusion of the investigation was obvious: The machine met all current and applicable standards requirements. Compliance to the current and applicable standards represents the best due diligence and the best engineering practice. The MOL released the machine back into production the next morning.
The decision to release the machine was welcomed by the client. This particular piece of equipment was critical to the output for the entire plant. The company was fulfilling a very important order and was working 24/7. Should the machine have been locked down for a longer period of time, it would have had very negative implications on the company’s ability to deliver its order on time.
Ivan’s fingers were reattached at the hospital the same night. However, I don’t know how functional he is going to be.
Ivan’s and Steven’s behaviour was further investigated by the MOL. There is a chance that both of them may be charged with violation of the Occupational Health and Safety Act.
As soon as I got back to the office, I received an urgent phone call from another manufacturer. They just had a serious machine accident. I rushed there to investigate.
The machine was approximately 15 years old. There was no proper guarding on the machine. The MOL had earlier issued 54(1) K orders to comply. It reads as follows: “Require the employer, at his or her expense, to have a professional engineer test any equipment or machinery and verify that it is not likely to endanger a worker [section 54(1)(k)]; and stop the use of anything, pending such testing [section 54(1)(l)].’
In order to fulfill the requirements of this order, the equipment must be upgraded to satisfy the requirements of the current and applicable safety standards. Once the equipment is upgraded and meets the requirements, it is ‘deemed not likely to endanger a worker’.
The process of upgrading begins with an audit. The audit consists of a complete hazard analysis and solutions recommendations, followed by the design of a safety solution. The safety solution must be effective and have only a positive impact on the productivity of the machine. During the design stage, all pertinent drawings and bills of material are created. It is very important to have engineered drawings because they enable that tender process, as well as produce a record of what has been done. The next step in this process is the build and the completion of a final PSR. As you can see, this is a necessary and relatively lengthy process.
We know from experience that it may take at least a month or longer to go through the process, depending on the complexity of the machine.
Unfortunately, this particular machine was one of many packaging machines in this manufacturing facility. Since the accident was a very serious one, the MOL was concerned about allowing the operation of similar equipment. Shutting down the packaging machinery would have a very serious impact on the delivery of the company’s products.
I speculated that this manufacturer would be charged with violations of the Occupational Health and Safety Act.
Based on Ontario’s Workplace Safety and Insurance Board (WSIB) data, there were 80,863 lost-time injuries related to machinery in 2009 in the province. I strongly advise manufacturers to be proactive to make sure that all of the equipment in their factories is safe.

Simon Fridlyand, P.Eng., of SAFE Engineering Inc., specializes in industrial health and safety concerns and PSR compliance. For more information, visit www.safeengineering.ca.

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