Abattoir crush fatality: Engineering standards for safe control design

Abraham Yak was crushed after inadvertently actuating a control while cleaning a machine according to the reports below.  A meat processor was found guilty on two charges relating to occupational health and safety.  The charges are not listed in these articles.  Neither the County Court or Austlii have a link to the judgment to date.  A phone call to the County Court requesting the judgement only resulted in a referral to the website.

Crushed while cleaning: company fined over worker’s death (The Age 13 February 2013)

Gippsland meat processor fined $380,000 (Worksafe Victoria 13 February 2013)

The issues tackled unfortunately do not seem to point the way toward reliable prevention of a re-occurrence.  For instance the judgement is said to have concentrated on training: “…on that particular day, the lack of training became extraordinarily evident”. This might not be representative of the judgement.  However, there should have been an analysis of the engineering standards of the machine.  Otherwise it could easily happen again.  It should be difficult to inadvertently activate the machine.  This is covered by engineering standards for safe control design such as the following:

Controls should be “…located or guarded to prevent unintentional activation” (Occupational Health and Safety Regulations 2007 (Vic) regulation 3.5.5(c))

“Control actuators, and especially start control actuators, shall and arranged in such a way as to avoid inadvertent operation.” (AS 4024.1401-2006 clause 5.4.2(c))

“Accidental actuation of (manual) start controls, as well as unexpected results from actuating these devices (e.g. start-up of a machine other than the expected one, or initiation of a movement in a wrong direction), shall be prevented by appropriate design, location, protection and marking of (manual) start controls (actuators).  (AS 4024.1603-2006 clause 7.2.1).

Take this machine control for example.  The stop button is proud and easy to access.  The start button is inset and difficult to inadvertently operate.  

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About John Culvenor

Hi, Thank you for taking a look at this blog. I work in engineering, ergonomics, creativity, design, training, etc. Often this is about helping solve legal puzzles through accident analysis. Sometimes it is about thinking up better designs for equipment, workplaces, and systems. This blog is about good design and bad design, accident analysis and how it can be done better, and how we can make a better, safer world by design!
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