Accident Advisory: Worker fatally injured by machine door

01 Jun 2020

Ref No.: 010620 (2)

UEN: S97SS0046G

Dear Valued ASPRI Members,

Accident Advisory: Worker fatally injured by machine door

Ref: 1920103 WSH Alert Accident Notification dated 26 February 2020

On 24 February 2020, two workers were on a work platform carrying out maintenance works on a scrap metal machine when the overhead door closed downwards and struck both of them. One worker was fatally pinned between the door and the work platform. The other worker sustained minor injuries.


Stakeholders such as occupiers, employers, principals and contractors in control of similar workplaces and work activities are advised to consider the following risk control measures to prevent similar accidents:

Safer machine by design
• Machines should be designed and built in such a way that it can perform the
   intended function without the need to put workers at risk of injury during
   operations and maintenance.
• Machines with moving parts must be designed such that workers are protected
   through machine guards or other protective devices. Should the workers be
   required to work below or near a movable part of the machine (the overhead
   door in this case), ensure that the movable part is properly secured (e.g. using
   safety retaining pins that can hold the door in place) to prevent accidental
   movement. As an added measure, the use of presence sensors may be used to
   stop door movement once a person is detected in the vicinity.
Energy lock-out and tag-out
• Always isolate, disconnect or discharge all hazardous energy sources (whether
  electrical, mechanical, pneumatic or hydraulic) and place the machine on lock-out
  and tag-out (LOTO) prior to maintenance or repair works. This is to prevent
  accidental machine activation and ensure that machine parts cannot move while
  the works are in progress.
• Incorporate the LOTO procedure into safe work procedures so that workers are
   guided on how they can carry out the work safely. Refer to SS 571: 2011 Code
   of Practice for Energy Lockout and Tagout for more information on LOTO
   requirements and procedures.
Machine declaration of conformity
• Ensure that the machine manufacturer or supplier has provided a “Declaration
   of Conformity”. A declaration of conformity is a formal declaration by a
   manufacturer or supplier that the machine meets all local safety requirements
   and relevant international standards.
• A declaration of conformity typically includes (non-exhaustive):
     – name and address of the manufacturer (or, where appropriate, the
        authorised representative);
     – information on machine model, type and serial number;
     – applicable safety requirements and standards that the machine conforms
        to; and
     – identity and signature of the person empowered to draw up a declaration on
        behalf of the manufacturer (or the authorised representative).
Worker training
• Ensure that workers are adequately trained and competent in machine operation
  and maintenance prior to assigning work. The training should cover hazard
  identification and the WSH aspects of the task at hand.
• Machine operators should be trained to:
     – understand the purpose of the energy lock-out and tagout;
     – recognise when lock-out activities are in progress; and
     – understand the importance of not tampering with the lock-out devices.

• Authorised personnel carrying out servicing and maintenance should be trained to:
     – identify hazardous energy sources;
     – carry out the LOTO procedure; and
     – safely apply (and remove) energy-isolating and lock-out devices.

• Where applicable, buyers of machineries should work closely with the
   machine manufacturer or supplier to provide user training sessions for
   machine operators and in-house maintenance personnel.
• Remind workers on the hazards and risks of working with the specific machine,
   for example, during daily toolbox meetings or prior to work commencement.
Worker communication
• Establish a suitable mode of communication (e.g. walkie-talkie) for situations
   where more than one worker is required to work on a machine. This is to
   facilitate enhanced situational awareness. This is especially critical for large
   machines when workers may not have line-of-sight to each other when working
   on the same machine.

Risk Assessment

Conduct a thorough Risk Assessment (RA) for all work activities to manage any foreseeable risk that may arise when working with machinery. The RA should cover, but not limited to, the following areas:

• The need for workers to interact with a movable part of the machine;
• The need for machine guarding or protective devices for movable machine parts; and
• Adequacy of supervision during operation and maintenance of machine.

Further Information

  1. Workplace Safety and Health Act
  2. Workplace Safety and Health (Risk Management) Regulations
  3. Workplace Safety and Health (General Provisions) Regulations
  4. SS 537: Part 1: 2008 – Code of Practice for Safe Use of Machinery Part 1:
    General Requirements
  5. SS 571: 2011 – Code of Practice for Energy Lockout and Tagout
  6. ISO 14120: 2015 Safety of Machinery – Guards – General Requirements for the
    Design and Construction of Fixed and Movable Guards
  7. ISO 14119: 2013 Safety of Machinery – Interlocking Devices associated with
    Guards – Principles for Design and Selection
  8. Workplace Safety and Health Guidelines on Safe use of Machinery
  9. WSH Council’s Case Studies for Metalworking Industry
  10. WSH Council’s Activity Based Checklist on Working Safely with Machines
  11. WSH Council’s 6 Basic Workplace Safety and Health Rules for Working with
  12. WSH Council’s Article Protect Against Machine Accidents
  13. WSH Council’s Toolbox Meeting Kit
  14. UK Health and Safety Executive’s Providing and Using Work Equipment
    Safely (INDG291 rev1)
  15. Waste Industry Safety and Health (WISH) Forum Information Document
    – Practical Advice on Lock-off Recycling/Recovery Machinery

Information on the accident is based on preliminary investigations by the Ministry of Manpower as at 1 April 2020. This may be subject to change as investigations are still on-going. Please also note that the recommendations provided here are not exhaustive and they are meant to enhance workplace safety and health so that a recurrence may be prevented. The information and recommendations provided are not to be construed as implying any liability on any party nor should it be taken to encapsulate all the responsibilities and obligations under the law.