Worker loses fingers at brewery

A Dorset brewery has been prosecuted for safety breaches after an employee lost two fingers in unguarded machinery.

The circumstances were:

• Hall and Woodhouse had re-located the grain dust extractor at their brewery in Blandford.
• Operatives had been tasked with emptying it when necessary.
• Hall and Woodhouse had failed to identify the risks associated with the grain dust extractor in its new location. 
• It was foreseeable that employees would try to deal with a blockage if one occurred and an alternative system should have been provided to prevent access by workers to dangerous moving parts.
• A worker was trying to clear a blockage in a grain dust extractor during a night shift on 27 August 2012.
• He reached into the chute of the extractor to dislodge the build-up, but his right hand made contact with the rotary valve, which was still running. His middle and index fingers were severed.

Hall & Woodhouse Ltd.  was fined £16,000 (inc. costs).

The HSE Inspector said:

"An employee has suffered painful and needless injuries because of the failure by Hall & Woodhouse Ltd. to put simple safety measures in place. This was an incident that could have easily been prevented by carrying out a suitable assessment of the risks presented by the new location of the extractor. This would have identified the need for guarding to prevent access to the dangerous rotary valve within the chute. The company should also have provided employees with information and instruction on how they wished potential blockages within the extractor to be dealt with. In the absence of these measures, an employee has suffered a serious injury.

Worker loses fingers in poorly guarded saw

Two businesses have been prosecuted for safety failings after an employee's hand was caught in a saw, resulting in debilitating injuries.

The circumstances were:

• Envirowales Ltd., were responsible for the day-to-day running of the Jamestown Industries lead recycling plant in Ebbw Vale
• An employee of Envirowales Ltd., was operating a saw to cut lengths of lead into smaller, more manageable pieces on 21 February 2012.
• The guarding on the saw was not effective and the companies failed to inform employees of the risks from the saw when retracted.
• The employee was not supervised at the time of the incident and there was no experienced operator working with him. 
• Training had been undertaken but it was not adequate to ensure that all employees understood the risks in place when the saw was retracted, or the procedure for removing material that had become jammed in the saw.
• He tried to dislodge a piece of lead which had become jammed, believing the saw blade was fully retracted and out of reach.
• However, his right hand made contact with the blade, severing his third finger. 
• He was taken to Morriston hospital, where he had his finger amputated above the second knuckle. The saw had also gone through the tendons and artery of his middle finger.

Envirowales Ltd and Jamestown Industries Ltd  were fined  £12,600  (inc. costs) to be split equally between Envirowales and Jamestown.

The HSE Inspector  said:

"This accident was foreseeable and both companies have fallen woefully short of the standard required by law. They both failed in their roles to protect workers by not properly guarding this machine. The injured employee should never have been placed in the position he was, and has suffered a debilitating injury as a result. Employers must fully assess the dangers associated with their work and put in place control measures. In this case, the risks associated with saws are well known, and should have been adequately controlled."

RIDDOR changes in October 2013

RIDDOR is due to change in October 2013, although the changes remain subject to Parliamentary approval.

The main changes are to simplify the reporting requirements in the following areas:

• The classification of ‘major injuries’ to workers is being replaced with a shorter list of
  ‘specified injuries’.
• The existing schedule detailing 47 types of industrial disease is being replaced with eight categories of reportable work-related illness.
• Fewer types of ‘dangerous occurrence’ will require reporting.

Specific injuries will now be:

• a fracture, other than to fingers, thumbs and toes;
• amputation of an arm, hand, finger, thumb, leg, foot or toe;
• permanent loss of sight or reduction of sight;
• crush injuries leading to internal organ damage;
• serious burns (covering more than 10% of the body, or damaging the eyes, 
• respiratory system or other vital organs);
• scalpings (separation of skin from the head) which require hospital treatment;
• unconsciousness caused by head injury or asphyxia; 
• any other injury arising from working in an enclosed space, which leads to 
• hypothermia, heat-induced illness or requires resuscitation or admittance to 
• hospital for more than 24 hours.

Work-related illness will now be:

• carpal tunnel syndrome; 
• severe cramp of the hand or forearm; 
• occupational dermatitis; 
• hand-arm vibration syndrome; 
• occupational asthma;
• tendonitis or tenosynovitis of the hand or forearm;
• any occupational cancer;
• any disease attributed to an occupational exposure to a biological agent.

Changes to dangerous occurrences are presently a bit obscure.
There are 21 instead of the present 27 dangerous occurrences, but they haven't said which yet.
We will keep you updated.

Man killed and 6 injured by flying gas cylinders

A man was killed and six other injured by flying gas cylinders at a construction project.

The circumstances were:

• Crown House Technologies Ltd of Dartford, Kent, was principal contractor for a construction project.
• They engaged Kidde Fire Protection Services Ltd, of Slough, Berkshire, to supply and install fire suppression equipment at the new facility.  
• This work was carried out by Kidde Products Ltd, also from Slough.
• The three companies involved failed to recognise the significant risks involved in the project or to carry out an adequate risk assessment. 
• The principal contractor and the main contractors failed to co-ordinate the scheduled work activities or to co-operate meaningfully in light of the risks. 
• There had also been insufficient training and supervision.
• 80 cylinders, nearly two metres high and each weighing 142 kg,  were stored without their safety-critical protection caps and left without being properly secured in racks.
• Other trades involved in the construction project were also working next to these potentially unstable cylinders, unaware of the deadly risks involved.
• One or more of these cylinders was de-stabilised and probably fell over, causing its unprotected valve to shear off near the cylinder neck. 
• This released an uncontrolled jet of liquified argonite gas under high pressure, the force of which caused the cylinder to move, colliding with others. 
• These, in turn, were also knocked over and sustained similar damage.
• A chain reaction developed rapidly and for several minutes shocked and terrified workers desperately sought shelter as they endured a barrage of heavy cylinders rocketing around them. This continued until 66 of the 80 cylinders had been discharged. 
• Some of the cylinders travelled at estimated speeds of up to 170mph and developed sufficient energy to penetrate walls and ceiling voids, travelling into more remote parts of the building.
• The deceased was walking with a colleague when he was struck by one of the argonite gas cylinders as they were propelled alarmingly around the building. He suffered multiple injuries and died at the scene.
• Several other workers, including electricians working in the argonite store room, suffered injuries and long term effects 

  

Crown House Technologies Ltd  was fined £236,393 (inc. costs)

Kidde Fire Protection Services Ltd  was fined £224,696 (inc. costs).

Kidde Products Ltd. was also fined £224,696 (inc. costs)..

The HSE  Inspector  said:

"Mr Johnston had no control over the chain of events which led to his tragic death. He died while going about his business as a result of the shortcomings of others. It is only by chance that this incident did not cause further fatalities. There is little evidence that those involved were competent to undertake this work, or that safe systems of work were provided, or that there was suitable cooperation between the contractors involved. Employees of other companies were allowed to enter the argonite store while it was potentially unsafe to do so, and there is no evidence that anyone explained the risks to them, or acted effectively to control these risks. This incident was devastating for his family and yet it could have been avoided had there been effective planning, management, monitoring and coordination of the relevant activities. Health and safety is sometimes dismissed as an unnecessary burden on businesses but this tragic case clearly demonstrates its true importance to those at the 'sharp end' of the industry."

Inadequate isolation procedure causes death in furnace

An accident at AETC Ltd., occurred because of inadequate isolation procedures which allowed a powered valve to close.

The circumstances were:

• Graham Britten,  a maintenance fitter, was carrying out maintenance in a vacuum casting furnace on 4 November 2009.
• The furnace comprises two chambers separated by the large sliding isolation valve.
• AETC Ltd did not have an effective isolation procedure for maintenance work on the furnace.
• AETC Ltd had failed to adequately train and supervise maintenance staff.
• The furnace control systems, intended to protect operators when carrying out routine cleaning within the furnace chambers, were inadequate and exposed them to unnecessary risk.
• Mr Britten had gone to the furnace with a colleague to fix a fault after the main isolation valve had become jammed part-way while closing.
• Mr Britten was standing on the rising table within the lower furnace chamber inspecting the valve when it suddenly closed, causing fatal head injuries.

AETC Ltd  was fined  £377,500  (inc. costs).

In sentencing, Judge T Bayliss QC said:

"At the time of the accident there was no robust system in place to ensure safety during maintenance. It was left to the discretion of the fitters. It was, I’m sorry to say, a shambles."

The HSE Inspector said:

"There were two issues here. Firstly, the furnace operators routinely climbed into the furnace to clean, thinking that when the furnace doors were open the valve could not move. This was not the case and they were continually at risk. Secondly, there was no safe system for maintenance work. There were no isolation procedures and, as a result, the fitters developed their own methods of working. The maintenance work that Mr Britten was carrying out was not unforeseen and the jamming of the isolation valve was a recurring problem which ATEC knew about. When the valve jammed, air pressure continued to build up in the cylinder that drives the valve such that, when the jam was cleared, the stored energy caused the valve to close rapidly with tragic consequences. Safe isolation procedures with training, supervision and monitoring would have prevented Mr Britten’s needless death."

Don't get caught out. Prepare a business continuity plan

Many companies pay lip service to disaster recovery plans. For a start, this is the wrong term; business continuity is a far more meaningful name, because it is more than thinking about fires or computer system major crashes. For example, what would happen if a key person was involved in a car crash. (This happened to me 30 years ago and people kept asking work questions from my hospital bedside.)

At an initial count, 25 to 30 scenarios need to be planned for to cover basic provisions, covering such topics as:

• People, eg what happens if key people are ill?
• Premises, eg fire
• Technology, eg what happens if key equipment breaks down?  What happens if the local phone system fails?
• Supplies, including key external services, eg what happens if a key supplier is unable to supply?
• Civil emergencies, including lack of accessibility to the site because of external factors such a major chemical spill on the industrial estate or accidents or flooding on access roads

Carry out a risk assessment, much as you would for health and safety, and assign scores for severity of the outcome and it's probability. Then, in descending order of risk:

1. Define steps to be taken to recover a situation.
2. Carry out step 1, plus where appropriate, define provisions to make such steps work. For example, with IT systems, not only is a back-up necessary, but it may be advisable to have an off-site back-up.
3. Carry out the above steps, plus make contact with appropriate organisations to organise the support they can provide and define how this may be organised.  For example, you may use another company to carry out operations which are unavailable because of the event.  Contact this company and arrange how this may be arranged, ie contact names and numbers. 
4. Carry out the above steps and, where appropriate, carry out a test of the plan.  This is typically essential where the provisions are technology-based.  For example, you need to test IT back-ups to confirm that they actually work.

 SSS can provide help with this. But whether or not you use outside help, it is essential that you do it.

Inadequate non-core operation results in fall through roof

Lack of a system for non-core operations was the underlying cause of a fall from height.
The circumstances were:

• An employee of  Paragon International Ltd., a vending machine supplier, was sent onto the roof to clean the guttering between two connected buildings. 
• No provisions were made to do the work safely, such as hiring a cherry-picker
• He was told he should try to stay away from the roof lights, but no practical steps were taken by the company to avoid this.
• The employee and another worker had to carry bags of debris to the top of the roof, walking on the metal sheets between the roof lights, so that it could be collected by a forklift truck.
• One of the men accidentally stepped onto a roof light and fell 6m into the accounts office below. He suffered bruising to his right side and leg, and injuries to his right hand and back.

Paragon International Ltd, was fined  £13,567 (inc. costs).

The HSE Inspector said:
"The worker was extremely lucky not to have been seriously injured or even killed when he fell through the roof light. If he had fallen further along the roof then he would have landed on the concrete warehouse floor. Paragon International knew the roof lights were fragile but he was simply told to try to avoid them, rather than any action being taken to keep him safe. The company should have carried out a proper assessment of the risks and then controlled them so that the work could be out safely. They could have used a cherry-picker, harnesses or safety netting, but none of these were chosen. An employee’s life was put at risk as a result."

SSS comment: This is a clear example of a failure to anticipate risks due to non-core operations. A company may have safe operations for its main business but fail to cope with something out of their normal expertise.  A simple permit to work system, which prompts a check of risks and how to control them is necessary for non-core operations.