Man dies during paper-cutting guillotine blade change

Those of you in the Printing Industry may have heard of the recent accident where a man lost his life whilst changing a guillotine blade.

I first spotted the risks of blade changing at a printing company about 12 years ago and have done 160 risk assessments of guillotine blade changing since then.  At training courses I always stress that guillotines are protected up to the eyeballs with light curtains, two-handed control, etc., during normal operation, but the same level of protection is not there during blade change.

My anticipated worst-case outcomes are:

• Amputation of the foot, or part of it, if the blade is dropped, or 
• Major lacerations if the blade is swiped horizontally against the body of the person changing the blade or someone nearby.  

I am stunned by this being a fatality.  We don't have the details, but it looks like this was a one-man operation.  Blood flow from a major laceration which, with available first aid support could have been stemmed, could not be tackled by the deceased on his own.

The system of work should be:

1. Use trained personnel for this.
2. Have the box as close as possible to the guillotine and at the same height (rather than being on the floor). 
3. Ensure that housekeeping is good and the area is free from trip and slip hazards.
4. Use appropriate tools. 
5. Where there are pedestrian/vehicle routes by the guillotine, barricade the area to protect others.
6. Avoid this being done as a lone worker operation; however, others must not be "within range" of the blade or distract the person changing the blade.
7. Whilst not being part of the blade changing operation, ensure that blades in the boxes are stored so that the cannot fall; good practice is to have a simple chain loop and hook so that the box is held against the wall.

This picture shows tools [4], covering blade edge, barricading [5] but housekeeping [3] is poor (trimmings on floor are a slip hazard), and where is the box to which the blade is to be moved?