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December 20, 2011

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Modified machine created dangerous gap

A manufacturer must pay £200,000 in fines and costs after a night-shift worker was killed at a toilet-tissue factory in Barrow-in-Furness.

Christopher Massey, 28, was struck by a piece of machinery while working at the Kimberly-Clark factory on 8 November 2007. The HSE prosecuted the company after its subsequent investigation revealed that a dangerous part of a machine, used to produce rolls of Andrex toilet paper, had been left unguarded.

The HSE discovered that the machine had been modified four months earlier, so that reels of two-ply as well as single-ply toilet paper could be fed through it. Part of the machine used to hold the large reels of tissue had been moved back so that another piece of machinery could be incorporated to handle the two-ply toilet paper. However, this created a potentially dangerous gap, which Mr Massey and other workers had used to check the tissue was being fed through correctly.

The gap in the machine gave him the best vantage point to check the tissue, and none of the workers had been told it was not safe to stand in that position. As he checked inside the machine at around 5.10am, it began to move a large, two-metre-wide reel of tissue into place, and Mr Massey was struck on the head by part of the machine. He died at the scene and his body was discovered by colleagues around 20 minutes later.

Preston Crown Court was told 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 s2(1) of the HSWA 1974 by failing to ensure the safety of its employees. The company, based in the UK at West Malling, Kent, was fined £180,000, and ordered to pay £20,000 in prosecution costs, at the hearing on 14 December 2011. The judge described the breach as a “misjudgement” on the part of Kimberly-Clark.

Speaking after the sentencing, HSE Principal Inspector Mark Dawson told SHP that the company failed to review its risk assessment after the machine had been altered. “Significant modifications were made to this machinery, which resulted in the creation of a dangerous trap point. Kimberly-Clark failed to notice this and, as a result, a young man in his prime was killed.

“None of the workers at the factory had received training on how to use the machine after it had been modified, or on how to safely check the tissue was being fed through correctly. This meant that, for several months after the modification, their lives were put at risk.”

Following his death, the company fitted two sheets of clear plastic over the gap, which allowed employees to check the machine without being put at risk. It fully cooperated with the HSE investigation and expressed its deep regret over the incident.

The victim’s father, David Massey, said: “Never a day goes by when we don’t think of our son, Christopher. We are still struggling to come to terms with his death and the pain will always be with us.

“He had so much to live for and we’ll never know or understand the reasons why he had to live a life so short. And still, four years on, it is hard to comprehend what happened. He went to work and didn’t return home.”

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