Date of incident: September 2021
Notice of incident number: 2021166970012
Employer: Food manufacturing company

Incident summary
Workers were making dough in a mixing room at a food manufacturing facility. A worker was scraping dough off the back inner wall of a mixing machine while it was shut off. Another worker (the operator of the machine’s control panel) asked the worker if he was finished scraping. The worker tilted his head and motioned with his hand, which he intended to signal that he had more scraping to do, and the operator restarted the machine. The worker repositioned himself and continued scraping dough. The worker was drawn into the machine and sustained a serious injury.

Investigation conclusions

Cause

• Worker caught in unguarded mixing machine. The mixing machine involved in the incident did not have adequate safeguards installed prior to being put into operation. The worker was scraping the inside of the unguarded machine while it was running and the agitator was moving, and he was drawn into the machine.

Contributing factors

• Lack of hazard identification. The employer did not examine the machine as required to identify that safeguards were absent and that the starting and stopping controls of the machine were not in reach of the operator. Even though the employer had purchased other mixing machines that were equipped with guards that covered the tubs during operation, the employer failed to identify that the machine involved in the incident required a guard. A hazard identification and risk assessment was not performed to identify and safely eliminate the exposure to unguarded moving machinery.
• Inadequate supervision. The employer failed to provide adequate supervision by allowing its workers to work around unguarded machinery and to access the inside of the mixing machine when it was not locked out. Additionally, the employer failed to ensure that workers left to oversee work activities were trained and qualified to do so.
• Unsafe work practices. The worker had access to the moving agitator in the machine during its operation. The employer’s written work procedures allowed workers to scrape the inside of the mixing machine even when it was not locked out.

Request the full report