In February last year, a 34-year-old worker’s head became caught and crushed in a cardboard processing machine.
The state coroner, Adam Nakhoda, has now ruled his death a work-related misadventure, stating that the worker bypassed a safety feature on the machine.
It contained a window that had to remain open for workers to use it safely. If the worker had kept it closed, he could have avoided sustaining the injuries which led to his death.
Channel NewsAsia (CNA) reported that Sun Zaitao worked as a production fitter for AMB Packaging. Located at 17 Senoko Loop, the company manufactures paper and cardboard containers and boxes.
Source: Google Maps
He had training in operating the machine that caused his death, named the Tai Yi TGF High Speed Flexo Printer Slotter Rotary Die-Cutter Inline with Folder Gluer machine.
The machine would process corrugated cardboard into cartons containing a customer’s designs. It achieved this by cutting, gluing, folding and stacking the cardboard.
Purchased in May 2019, the machine additionally had six machinery components and a viewing window at its bundle stacker portion where it stacked items.
Spanning 0.9m in height and 0.8m in width, it contained an interlocking guard. If the window was open while a worker was using the machine, the guard would automatically cut electrical supply to the device.
From Nov 2021, Mr Sun had the specific task of operating the machine.
On 11 Feb 2022 at about 4.20pm, CCTV footage showed Mr Sun leaning his upper body through the window of the machine while it was in use.
Mr Nakhoda said he was likely trying to clear the built-up cardboard waste. Mr Sun then leaned further into the machine to remove a carton.
“It was likely that Mr Sun’s head was then caught by the upward moving collection mechanism and was then trapped between the collection mechanism and the stationary pair of metal pieces,” CNA quoted the coroner as saying.
He had either fallen or got pulled in by the machine’s moving parts into the bundle stacker area. This was where authorities found him dead.
Following his death, the Ministry of Manpower (MOM) discovered that the interlocking guard had undergone tampering, noted CNA.
A key was inside a device by the window frame, forcing it to remain open while the machine operated.
The bypass allowed the machine to continue operating without pausing.
Typically, the machine would stop to let workers remove the accumulation of cardboard waste near the window. Bypassing the safety feature thus allowed workers to remove the waste through the window without stopping the machine.
Reviewing the CCTV footage, MOM said that Mr Sun and a printer supervisor leaned through the window five and 11 times respectively between January and February 2022.
The workers would do so to clear sub-standard cartons and remove cardboard waste with a printer operator also observing them in the process, according to investigations by MOM.
The company received a stop work order after Mr Sun’s passing and reinstalled the interlocking guard, ensuring it worked.
On 21 Feb last year, the Workplace Health and Safety Council (WSH Council) issued an alert recommending safety measures.
They included:
The coroner described the tragedy as an avoidable one, with the machine having a safety feature protecting workers from touching moving machinery components
A trainer from the maker of the machine had also informed Mr Sun and other workers clearly that the closure of the window was vital when the machine was in use.
If the guard was working, it would have stopped the machine when Mr Sun opened the window. This would allow him to remove the waste without getting caught by moving parts.
Evidence, however, showed that the bypassing of the interlocking guard had taken place since September 2019. Around the same time, it had been commissioned for use at the factory.
The coroner ultimately urged stakeholders operating similar machines to follow the safety measure recommendations by the WSH Council. Doing so would prevent such incidents from occurring again.
Also read: Worker Dies After Being Crushed Between Mobile Crane Parts In Mandai, MOM Investigating Accident
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Featured image adapted from Google Maps.
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