Worker killed by modified machine

Kimberley-Clark, the toilet tissue manufacturer, has been fined £180,000 after a night-shift worker was killed at its Barrow-in-Furness factory in November 2007. The company was also ordered to pay costs of £20,000.  Christopher Massey, 28, was struck by a piece of machinery which had been left unguarded after modifications were made to it. HSE’s investigation found that the machine, which was used to produce rolls of Andrex toilet tissue, had been adapted four months earlier so that it could handle both two-ply and single-ply paper. The gap created by this modification was used by operators to check that the tissue was being fed correctly.

Mr Massey was killed when the machine began to move a two-metre wide reel of tissue into position as he was making a check through the gap. Mr Massey was struck on the head and died at the scene.  Preston Crown Court heard that the factory had been short-staffed on the night of the incident, with two of the four workers in the team off sick. Mr Massey was moved to work on the part of the machine that fed through the giant reels, despite not having had training on how to operate it since its modification.  Kimberly-Clark Ltd pleaded guilty to a breach of Section 2 of the Health and Safety at Work Act.  Following the accident the company fitted two sheets of clear plastic over the gap, which allowed employees to check the machine without being put at risk.

CRS Opinion:

Unfortunately we have heard of a number of accidents involving modified machinery. Modifications are often made to speed up production, for example to allow a jam to be cleared on the run without the need to stop and reset the whole machine. Sometimes a modification can be forgotten about for years and only comes to light after an accident.  One problem is that daily machinery start-up checks only show that the guards fitted are working as expected. They do not show that the guards are correct for a particular application or test their effectiveness in preventing access to dangerous parts.  Where changes are made to the design, function or safety of machinery, the modifications should be assessed against the requirements of the Provision and Use of Work Equipment Regulations (PUWER) 1998. Among other things, PUWER

requires that work equipment is safe, suitable and used only by people trained to do so.  If a machine is altered substantially, for example significant new hazards or control methods are introduced, it may be considered a ‘new’ machine, in which case a conformity assessment should be carried out.