- The incident occurred on 6 February 2012 at the Emballator UK Ltd factory in Tyersal, Bradford, which manufactures tin cans.
- A fault had developed on the usual, modern, pallet turner, which is used to turn bulk tin plate.
- Mr Wain, a coating assistant at the plant, had been told to use an older machine to turn the bulk tin plate
- He had no experience of using the older machine and a colleague gave him a demonstration of how to use it and how to load the pallets for turning.
- Mr Wain used a forklift truck to pick up a pallet of plates, loaded the machine the way he had been told - wedging the load using empty pallets - and switched it on.
- Moments later, after the machine turned 180 degrees, he saw the plates and pallets moving.
- He tried to get out of the way but the full load of metal plates spilled out of the machine in a weighty waterfall, trapping his foot against the floor.
Part of Mr Wain’s big toe was severed and the sole of his foot was split. Surgeons managed to reattach the next two toes and he needed plates put into his ankle and screws into his lower leg. He was informed earlier this year by the hospital that his foot and lower leg may need to be amputated.
The HSE found that:
- Emballator UK Ltd had failed to provide both safe equipment and a safe system of work.
- There was no clamping mechanism to retain the pallet of metal plates within the rotating machine
- There was no guarding to keep operators from the machine during turning.
- The firm had not identified the risks involved with using the older machine, and in particular the risk of the plates falling out.
- Mr Wain was not supervised whilst he used the machine for the first time.
- No checks were made that he understood the risks and the precautions to take.
The HSE Inspector said:
"Everyone has the right to come home from work safe and well. But David Wain suffered life-changing injuries in an incident that was preventable. Emballator UK Ltd failed in their duties to provide a suitable machine for turning pallets and a safe method of operation that Mr Wain could use. Manually securing the load in an open box by means of wedges or empty pallets is not a sufficiently reliable method of securing the load. A proper examination of the risks would have shown that there was a danger of the load shifting and falling from the machine, during or after turning. A simple clamping mechanism would have secured it, and was indeed applied to the newer machine. It is also essential that checks are made by managers to ensure operators are trained and competent to use the machines they provide, understand the risks and associated precautions to take."
Source: HSE 1 May 2013 Y&H/93/13