Fatal accident – Arjo Wiggins paper mill, Ivybridge

The deceased had worked at the paper mill for 17 months.
Details of the incident
The deceased was attempting to remove paper from a drying cylinder and became
trapped between the drying cylinder and a dryer fabric roll. This area is protected by a gate
guard which is secured by a padlock to prevent access when the paper machine is running.
The deceased went through the gate to enter into the area inside the paper machine while it
was running. He died later in the hospital from his injuries.
SAFETY ALERT
Front close fitting fixed
face guards
Start of the afterdryer
section Access gate
Following the incident, all production activities on the site were stopped and representatives
from the Police and Health & Safety Executive (HSE) came to the site to investigate the
cause.
On the afternoon of Wednesday 29th April, the HSE stated that, based on the information that
they had gathered, and subject to the following action agreed with the HSE, production
activities could commence.
• The system for control of keys used to unlock safety guards would be changed to
ensure access to hazardous areas is prevented.
HSE investigations into the root cause and exact circumstances surrounding the incident, with
the full co-operation of the company are still ongoing.
In the meantime the following actions will be taken;
• A complete review of guarding will be carried out to identify where improvements could
be made.
• Replace padlocked guards with either fixed guards, or interlocked guards, where
access is required on a regular basis.
• Review operator training procedures for non-routine tasks to ensure that they are clear.
General view of the area
with the access gate open
Possible
position of the
deceased
at the time of
the incident
Ingoing nip
between felt
roll and the
drying cylinder
CPI and Unite the Union – Actions for consideration at all paper mills
All companies are strongly advised to review their current operating procedures against the
above information, in particular
• a risk assessment must be made on all areas where there is a likelihood of manual
intervention.
• care must be taken that the risk assessment is for both standard and non routine
operations e.g. always consider, machine running without a sheet, heaviest/lightest
grammage, maintenance operations, abnormal conditions etc.
• where such a situation is identified then immediate action must be taken to eliminate
the risk using BS EN standards 294; 1992 (safety distances to prevent danger zones
…) EN 349:1993 (Minimum gaps to avoid crushing of parts of the human body) EN
1034: 2005 (Safety of machinery for the design and construction of paper making and
finishing machines), as a means of ensuring that you are working to an established
standard.
• review of guarding standards around all machines, involve safety representatives and