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Issue 76
This month, we focus on four recent incidents where businesses failed to ensure workers were kept safe while working with machinery. In two of the cases, workers sustained life-changing injuries because inadequate controls were in place while the machinery was being cleaned and maintained. In the other two cases, the existing controls were not operational or had been removed, and the alternative controls put in place were not sufficient to protect workers. Two of the cases resulted in prosecutions and substantial fines. The other two cases led to enforceable undertakings between the regulators and the businesses.
“I think I found the problem.”
Two prosecutions after workers sustain injuries while cleaning and maintaining machinery
The failure to have adequate procedures and arrangements in place while machinery was being cleaned and maintained has resulted in significant injuries to workers and health and safety convictions for two businesses.
In February, a Christchurch bakery was fined $200,000 and ordered to pay reparations of $45,500 after a worker’s hand was pulled into a machine’s rollers. The
41-year-old father’s index finger was amputated, his thumb partially amputated, and his middle finger crushed.
The incident occurred when the worker was cleaning the machinery following maintenance. While his hand was in the machinery, another worker turned it on. WorkSafe highlighted that this was able to occur because of the failure of a fundamental safety control – lockout/tagout.
Lockout is the process of turning off machinery and applying a physical lockout device to its lockout point (for example, a disconnect switch, isolator switch, or circuit breaker). Types of lockout devices might include padlocks, chains and hasps. More than one lockout device may be used. Lockout prevents energy from being transmitted or released to machinery so it cannot be restarted (or cannot restart by itself). Machinery must be locked out safely and effectively before being serviced, if it is reasonably practicable to do so and if there is a potential for it to cause harm.
WorkSafe said that in this case the company had also completely missed identifying the crushing hazard from rotating parts within the machinery in its risk assessment, and that despite the company holding extensive documentation, workers had never seen lockout tags used, did not know where equipment was kept, and had not been trained in essential procedures. WorkSafe’s guidance says that businesses must have safe and effective lockout procedures and must make sure workers are trained in the procedure or supervised when they carry out the procedure.
The most up-to-date WorkSafe data (from January 2024 to December 2024) shows that there were 516 injuries resulting in more than a week away from work after people were trapped in moving machinery or equipment – an average of 43 injuries per month. In the manufacturing sector alone, there were 162 injuries over the year, in agriculture, 36 injuries, and in construction, 93 injuries.
On the other side of the Tasman, a similar incident led to a West Australian mining services company being fined AU$750,000 and ordered to pay $6,702.70 in costs after a heavy diesel mechanic sustained a serious crush injury and a left upper arm fracture while performing maintenance on a conveyor when it was in use.
As the worker tried to remove built-up wet material from the adjusters of the conveyor belt, one of his sleeves caught in a nip point—a location in machinery where two moving parts come close together—and the worker became entangled in the machine.
The company had a procedure in place for isolation and tagging (lockout/tagout) but there was no safe work procedure or similar document specific to the work being carried out on the belt at the time of the incident. This was despite the fact that in the time leading up to the incident, the work the victim was undertaking needed to be carried out approximately once each day.
WorkSafe Western Australia said that failures to adequately enforce isolation of conveyors to ensure the safety of workers are still far too frequent, and this incident was an example of the consequences of such failures. It said the company could have easily and inexpensively enforced isolation procedures to ensure the conveyor was de-energised before any worker accessed it.
Enforceable undertakings accepted after workers injured in faulty machinery
WorkSafe has recently accepted an enforceable undertaking (EU) after a worker suffered amputations to four fingers when her hand was pulled into an unguarded machine.
At the time of the incident, the worker was operating a meat mincing machine at an Asian butchery on Auckland’s North Shore. The machine's original safety guard was not in place, having broken off approximately two months earlier. While staff had been reminded to “take care” when operating the machine, including by using a plastic pusher and appropriate gloves, the machine continued to be used without the guard.
The machine was permanently decommissioned shortly after the incident. An independent technical assessment confirmed that the machine did not meet current safety standards in its unguarded state. WorkSafe investigated and accepted an EU proposal from the company in December last year.
An EU is an agreement between WorkSafe and a duty holder made under the Health and Safety at Work Act 2015 (HSWA). It is entered into voluntarily by the duty holder following a breach (including an alleged breach) of HSWA and, once in place, is legally binding. It is generally used as an alternative to prosecution.
As part of the EU, the company will pay undisclosed financial amends to the injured person. It will also develop a culturally appropriate “Good Work” toolkit, supported by “Knowby” learning modules, to communicate health and safety information in Simplified Chinese. Content will incorporate Chinese values, and the toolkit will be distributed within the Chinese business community with facilitation and support to encourage uptake. The toolkit will focus on providing guidance and templates based on good work principles while also addressing how to manage risk within a business.
In addition, the business will publish a “Lessons Learned” case study in Safeguard Magazine to share insights and promote industry-wide learning and provide a $2,000 donation to the New Zealand Qionghai Association to support community engagement and wellbeing initiatives.
All up, and excluding the amends paid to the victim, the minimum estimated cost of the EU to the company is $53,340.
WorkSafe accepted six EUs in total last year. You can read a summary of each of them on the regulator’s website.
Meanwhile, in Australia, WorkSafe Victoria has also recently accepted an EU after a worker’s arm was injured while cleaning machinery at a Wangaratta factory. The total estimated cost that will be spent to meet the terms of the EU is AU$170,800.
The incident that gave rise to the EU occurred in June 2023. Two workers were told to clean a machine used to make medium density fireboard (MDF). The machine had two rollers positioned in a way that created a danger area when in operation.
The danger area had been covered by a hinged guard fitted with an interlock which stopped the rollers when it was opened. However, the interlock system was not working, and management had been told about this.
As an interim measure, a safety lanyard and padlock were placed on the closed guard to prevent access until a new interlock was installed. Cleaning was only to be performed under supervision by an electrician once power was isolated from the plant.
On the day of the incident, the two workers were provided with the key to the padlock and left unsupervised to clean the machine, which was not powered down.
One of the workers was holding a rag that became caught, pulling his arm into the rotating rollers up to his elbow. The tissue above his elbow was damaged to the extent that it required skin grafts.
The EU requires the company to:
- Develop a platform for accredited online training across safety, compliance and competency development.
- Establish a safety committee with budget to identify and prioritise site hazards and develop and implement practical solutions.
- Design and implement a digital safety program tailored to the site’s environment to formalise and enhance the current paper-based process.
- Fund the development of enhanced safety and leadership training modules for students and apprentices in the timber industry.
WorkSafe Victoria commented that when faulty machinery including those without working safeguards is used, it's a case of when, not if, a serious or life-changing incident will occur.
This newsletter is published as part of Vero Liability’s commitment to supporting better work health and safety outcomes for all New Zealanders. We want everyone to go home safe.
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