Packaging Machine Accident
Case Synopsis: A process engineer was summoned to resolve a problem on a packaging machinery line that produces a continuous roll of labels for consumer products. The packaging machines print images on two continuous webs of material and laminates them before winding the finished product onto large rolls being shipped to customers. The engineer was asked to troubleshoot a laminating machine problem that was affecting one edge of the material and ruining the finished product. He isolated the cause of the problem and attempted a minor correction with the packaging line in operation. Unfortunately, his right hand was pulled into an unguarded in-running nip point formed between two rotating rollers as he made the adjustment. He was able to reach an emergency stop cable after his hand was trapped and injured in the machine.
Expert Analysis: The packaging machinery line involved in the accident was originally designed, built and installed in another production facility. The manufacturer subsequently upgraded the line and relocated it at the customer’s request.
Two safety standards were applicable to the design, manufacture, and modification of the laminating machine in the packaging line. The standards required guards for in-running nip points within reach of operators. Accordingly, the in-running nip point that injured the engineer should have been safeguarded. The manufacturer could have designed and installed guards without substantially increasing packaging machinery cost or operation. Guards were subsequently designed and installed after the accident.
Result: An engineering analysis determined the machine should have been equipped with guards for the in-running nip point hazard when it was upgraded and relocated. The analysis also demonstrated that the accident would have been prevented if the machine was equipped with guards in accordance with applicable safety standards as well as fundamental engineering principles.