A combination of work-at-height and moving-machinery risks conspired in an incident in which a worker suffered a traumatic amputation of his right arm.
Jedburgh Sheriff Court heard how, in February 2008, Bing Neil was working at John Hogarth Ltd, a producer of oatmeal ingredients based in Kelso, Roxburghshire. The manufacturing process produces a by-product used for animal feed, which is transferred from one area of the factory to another via a series of pipework and paraphernalia.
Mr Neil was attempting to clean a rotary valve among the pipework four metres above the ground, when he slipped. His right arm became entangled in the exposed valve and the rotor drew his arm into the mechanism because it had not been isolated from its electrical supply.
Suspended above the floor, his arm then severed approximately 10cm below the elbow. He fell to the ground screaming, at which point a colleague ran to his aid and an ambulance was called.
Mr Neil, who is in his sixties, is permanently disfigured and impaired as a result of his injuries, and has not returned to work.
An HSE investigation into the incident revealed that workers could only access the rotary valve by a combination of climbing a propped-up ladder, walking along a narrow beam, and then standing or sitting on a small wooden plank. This procedure was usually followed at the start of every shift to ensure the valve was clean.
The investigation also revealed that the on/off controls were at ground level but the isolator switch was screwed to the underside of the roof above the valve. According to investigating inspector Peter Dodd, the difficulty in accessing the cut-off switch meant it was not always isolated during the cleaning procedure.
The inspector issued two Prohibition Notices: one to prevent access to the rotary valve; and the other to stop work in the vicinity owing to a risk of fire and explosion from accumulated flour dust and the proximity of an ignition source.
John Hogarth Ltd was fined £16,750 on 29 July after pleading guilty to breaching section 2(1) of the HSWA 1974. No costs are awarded in Scotland. Since the incident, the company has fitted a compressed-air line to the body of the valve. To clear a blockage, operators now just operate a valve at ground level, which introduces a puff of air that clears any blocked material.
A safe back-up procedure is also in place, whereby workers can clear blockages by accessing a fixed metal staircase and working platform.
Commenting on the combination of risks prior to the incident, inspector Dodd said: “This tragedy should never have happened but it took this incident to occur before the company assessed the risks with the cleaning operation of the valve. They have demonstrated that the introduction of simple and inexpensive measures have eliminated the routine need for both work at height and in close proximity to machinery, which could not at the time be easily and readily isolated from its electrical supply.
“It is the clear duty of those who create risks to manage them and to implement safe systems of work, particularly for work at height, which is the most common cause of serious injury in the workplace.”
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I am somewhat surprised at Inspector Dodd’s comments regarding the use of a compressed air line to blow away blockages from the rotary valve, since this will create the very dust that was referred to elsewhere in the write-up as a potential fire / explosion risk. I presume that the applicable DSEAR risk assessments and hazardous area classifications were also carried out; otherwise, I fear that the HSE may be returning to this site at some later stage…..?