A food manufacturer has been ordered to pay fines of more than £800,000 for safety failings after two separate incidents led to two workers having their fingers amputated.
On 16 November 2022, a 22-year-old worker at Pork Farms’ bakery in Nottingham had one of his fingers amputated after his hand became trapped trying to clear a blockage on a conveyor. Little more than a month later, on 24 December 2022, 19-year-old Mahamad Hassan also had a finger amputated after his hand came into contact with a rotating conveyor driveshaft at Pork Farms’ nearby Riverside Bakery. We spoke to HSE inspector Tim Nicholson about the two cases and how he investigated both.
INCIDENT 1
The first incident occurred at Tottle Bakery, which makes pork pies. The incident involved a chain conveyor, which is used for moving trays of pork pies.
‘On the chains there are plastic “flights”, which stick up from the chain to push the trays along,’ explained Tim.’ The chain conveyor leads into a T-junction with another conveyor – it pushes the trays onto this other conveyor, which then takes the trays away – and the incident happened at this junction.
‘The area was covered by a guard that was hinged, so it could be opened. There was an interlock on the hinge mechanism so when the guard was hinged open, it should have stopped the machine working. In this incident there was a blockage of trays in the area and the worker opened the hinge guard to clear the blockage. He noticed that the chains had stopped in slightly the wrong position; the flights were slightly out of sync, which was causing the blockage of trays.
‘The worker tried to manually move the chains and get the flights out of the way but, as he did that, it tripped a sensor on the machine and the conveyor went through a cycle. As that happened, it dragged his hand between the sprocket of the drive system and the chain, which led to his significant injuries.’
INCIDENT 2
Just over a month after the HSE commenced its investigation at Tottle Bakery, it received a RIDDOR report for an incident that occurred on Christmas Eve 2022 at Pork Farms’ Riverside Bakery, just around the corner from the Tottle Bakery.
‘This was another incident involving a conveyor – albeit a line shaft conveyor in this case – that had also resulted in an amputation,’ explained Tim. ‘This line shaft conveyor featured metal rollers on the top, below these was a driveshaft that runs the length of the conveyor, with drive bands driving rollers individually where needed.
ULTIMATELY, IT ALWAYS COMES DOWN TO RISK ASSESSMENT AND MAKING SURE THESE AREN’T JUST A PAPER EXERCISE
‘In this case, the space between the rollers on top of the conveyor were sufficiently wide to fit a hand or arm through. So it was possible to reach the driveshaft below, although free-spinning spacers on the shaft itself should have prevented direct contact with it. What happened in this instance was that Mr Hassan was wearing gloves and his glove came into contact with something on the driveshaft. That then drew his hand in, severely damaging his fingers.’
THE INVESTIGATIONS
Although both the Tottle and Riverside incidents involved conveyors, the safety watchdog treated the incidents as two separate investigations, because they were different styles of conveyor and the circumstances around the two incidents were different.
‘However, when we realised the Riverside case was another conveyor incident with amputation injuries, and it became a full investigation, it made sense to pass that on to me as I already had some involvement with Pork Farms with the Tottle Bakery case,’ Tim explained.
As is normal with any incidents of this kind, the investigation is planned to allow investigators to obtain an understanding of what happened from talking to witnesses and reviewing relevant documents – such as maintenance records, training records, copies of safe systems of work and risk assessments, for example.
‘The Riverside incident was more challenging in terms of getting an understanding of what had happened,’ continued Tim. ‘One of Pork Farms’ initial responses was to decide the line shaft conveyor didn’t actually need to be powered at all – it worked fine under gravity for their needs. So by the time we were on site, Pork Farms had removed the conveyor’s drive system.
‘That was a fair response from the company to remove the risk altogether – our first job as inspectors is to ensure there is no ongoing risk, so Pork Farms weren’t trying to hide anything – but from an investigating point of view, it made it slightly trickier to get an initial visualisation of what had happened.
‘Fortunately Pork Farms had another conveyor of a similar style on site and we were able to look at that to help understand what had happened. The company had taken photographs immediately after the incident for its own accident investigation and we noticed relatively quickly that in those photographs we could see a shiny section of the driveshaft, which suggested that some of the spacers that prevented direct access to the driveshaft were missing and it had ultimately pulled Mr Hassan’s hand in.’
THE FINDINGS
In both incidents, there were similarities in that there were failings in guarding standards, and also in maintenance, said Tim.
‘In the case of the first incident at Tottle Bakery, one issue we identified was the interlock on the guard hinge wasn’t suitable and the cam that operated it had come loose, so when the guard was opened the interlock didn’t stop the machine. Anybody opening that guard would have expected the machine to not operate while the guard was opened.
‘In the case of the Riverside incident, the line shaft conveyor was missing spacers from its driveshaft.
DON’T JUST WALK PAST, KEEP QUESTIONING THINGS EVEN WHEN YOU HAVE TASKS OR MACHINERY THAT HAVE BEEN THE SAME FOR A LONG TIME
‘What differentiated the incidents for me was that, at the Tottle Bakery, the blockage of trays were a fairly common occurrence and operators knew it was the position of the flights on the chains that caused it. However, there was no clear safe system of work or instruction provided on how to address this issue, so that had led to operators coming up with their own ways to do it.
‘At the Riverside Bakery, it’s not quite clear how Mr Hassan’s hand went through the rollers. However, the need to prevent access to dangerous parts of machinery – such as driveshafts – whilst they are in operation is well established. It shouldn’t have been possible to make contact with the rotating driveshaft.
‘In addition, following the incident, the company recognised that this conveyor didn’t need any system of drive at all. Had that been identified earlier, this incident would have never occurred.
THE PROSECUTION
From a practical point of view, it was decided to keep the cases separate and then, when they were passed to the HSE’s Legal Services Division at the end of the investigation for consideration for prosecution, it decided to keep the cases separate, although they were dealt with at the same sentencing hearing.