The untimely start of machines: what are the factors …

Brescia, 10 Mar – As mentioned in the file. Inail “Premature start of fixed and wheeled vehicles“, Which refers to the accidents contained in the database of the system for monitoring fatalities in the workplace, in the system” 6.3% of cases of fatalities registered concern dynamics due to premature or inappropriate start-upi.e. incidents in which a worker is injured after a sudden and unexpected movement of a vehicle, machine or equipment present in the work area.

And the untimely start-up of a vehicle is therefore fifth type of accident among those registered in the system database “.

Based on these data, which show how widespread, often serious and fatal, injuries resulting from the timely or inappropriate start-up of fixed or movable equipment are, today we focus on two cases of accidents linked, in this case, to the onset of Some fixed equipment. / installations, in particular a loading system and a mechanical press.

The presented accident dynamics are taken from the INFOR.MO. archive files, a tool for qualitative analysis of accident cases associated with the monitoring system for fatal and serious accidents.

These are the topics covered:


Training in the specific risks of operators using machine tools and forklifts (Article 37 of Legislative Decree 81/08)

Accidents due to premature or inappropriate starting of machines

That first case relates to injury to a worker with duties regarding responsible for the loading system in the compost fermentation tunnels.

In the start-up phase of the north side of the plant, the worker, a temporary employee, climbs up the service corridors, which are located at a height of 6 m from the ground. It climbs over the parapet and places itself on top of the stationary horizontal conveyor belt to perform a cleaning with a fork of the area where it cuts the same belt on the south side that is in operation.

Before entering the dangerous place, he does not operate the emergency button at the beginning of the conveyor, as this action would have completely blocked all the systems. The colleague who works together at the same plant and is on the ground, after completing all preparations for the start of production, starts the north factory and the worker, due.conveyor drive which he is working on, he equalizes by falling into the confluence area of ​​the two horizontal conveyors 8 cm apart, and thus remains trapped and crushed in several seats between the two main rollers on the conveyor belts.

Subsequent investigations revealed that “the cleaning carried out from above the conveyor belt was common practice when there was a significant amount of straw between the two conveyors. The employer and the foreman did not supervise the workers’ correct use of the plant and the injured party had not received training” .

Furthermore, “the plant built by the same company in 2013 is not certified and has no use and maintenance booklet, it is not equipped with safety barriers with a locking system that prevents access by dangerous moving parts and the system command point does not allow full visibility of the same, which is expanded in an area of ​​about 50×20 m “.

The start-up of the system “is delayed and equipped with an acoustic alarm that is not audible at all points of the system with special reference to the area affected by the accident”.

In addition to the training shortcomings, these are i.a. causal factors can be found on the map:

  • the injured person “climbs over the breastplate and places himself on the stationary conveyor belt to perform a cleaning”;
  • another worker “starts the rollers without checking the presence of the colleague”;
  • “System not equipped with locked security barriers for secure access”;
  • “The start of the system is equipped with an acoustic alarm that is not audible”.

That according to sag it is about an injury when using one mechanical press.

While a worker is placing shims on the matrix of an iron-cutting shape with several sequences, the colleague gives consent to start the press.

The press is equipped with “a pulpit with double simultaneous pressure control (dead man) and equipped with both vertical and horizontal intangible barriers to protect the dangerous loading area of ​​the press”.

The investigation after the accident (death occurred by crushing in several places) “showed that:

  1. the horizontal photocell had been excluded, which would have prevented the press from being activated in case of access to the mold;
  2. the colleague (temporary staff who had been on duty for about 30 minutes) had not been adequately trained in the risks “.

These, ie causal factors discovered:

  • “Double-sided mechanical press with escaped photocell”;
  • “The colleague starts the press (striking mass) without checking the position of the injured person”.

Premature start-up of machines: risk factors

To provide some useful elements for prevention, we take from the aforementioned sheet. “Premature start-up of fixed and wheeled vehicles”, some indications of risk factors.

It is stated that from the analysis carried out of 100 cases of accidents registered in the archives of the National Monitoring System for Fatal Accidents, with regard to the issue of early start, “it appears that:

• that 67% of the events involved wheeled vehicles used for transport activities;

• that 33% fixed assets involved, both lifting equipment and production facilities “.

In terms of fixed funds the machines involved are generally “production machines and lifting equipment. With regard to the former, there is in all cases a misuse in use, accompanied in 90% of cases by problems related to the machine in terms of its setup (due to the absence of protection or control devices against unintentional start) or malfunction “.

With regard to the dynamics involved in lifting equipment, “in almost all the cases analyzed, there is incorrect use of machines or procedural errors by the injured party or a third party present, in most cases these have emerged as usual practice in the company. found critical problems related to the working environment due to the lack of delimitation of the hazardous area in the vicinity of the machine’s operating area and / or communication errors between the test subjects present. Regardless of the type of stationary vehicle involved, one third of the accidents analyzed occurred during an operation on the machine, mainly during a general maintenance phase and minimally during use for cleaning, adjusting or correcting operations after the machine itself has been blocked. these cases are the determining factors found: the absence of guards or locking devices on the machine that are subject to intervention; improper use or procedural failure of the operator due to lack of power supply to the machine or inappropriate reactivation of the same in the presence of other workers in the work area.

We conclude by referring to the full reading of the sheet, which also reports the risk factors associated with accidents that occur with untimely start-up of wheeled vehicles used for transportation activities.

Tiziano Menduto

INFOR.MO website: in the article we presented sheets number 4867 and 10217 (accident archive 2002/2018).

Download the maps from which the article was taken:

Learn from errors – Untimely startup of machines – files. 4867 and 10217.

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