Analysis of a Machine Accident That Could Have Been Avoided

by Jan 5, 2021Machine Safety

According to the IRSST’s annual indicators on occupational injuries, the number of work accidents fell sharply between 2007 and 2012 (22% decrease in injuries with loss of time later compensated) (Duguay et al., 2016). However, in 2018, there were 62 fatal occupational accidents (CNESST, 2019). If we include deaths linked to occupational diseases, 226 are to be deplored in 2018 alone. Much prevention work therefore remains to be done.

In December 2017, a worker working in a company specializing in retrieval and sorting of recyclable materials died while picking up debris accumulated on the ground near a conveyor. In fact, the investigation of the accident reveals that he leaned under the conveyor and his clothing (balaclava) was pulled into a nip point, causing the worker to be strangled.

The causes of this accident are of two kinds:

  • On the one hand, the worker accesses a hazardous area without having to remove any guard or protector (the hazardous area is not secure)
  • On the other hand, he accesses the equipment for a cleaning task while it is still active and operating.

Note that the worker was wearing a loose fitting garment (balaclava) which is the origin of the pull towards the nip point. In addition, there was no safe working method for daily cleaning. According to other workers, suitable tools are available, but can be kept far away which occasionally causes the former not to go and get them.

The company was in the process of securing the conveyors and had started installing fixed guards. The risk had therefore been clearly identified. However, while waiting for the installation of the guards, no additional risk reduction measures (E.g. work method, training, etc.) were put in place.

Here, the worker’s death could have been avoided if:

  • The hazardous area was not accessible,
  • An energy control method was applied,
  • The worker was wearing well-fitted clothing, as opposed to his loose-fitting garment, and had used an appropriate tool.

To minimize the probability of accidents, you need to perform a risk analysis study in your business. This will allow you to secure your equipment and develop safe working methods. Finally, training your workers to make them aware of the hazards present in their environment and their workstations will allow them to recognize dangerous situations and eventually establish a good health and safety culture in your company.

If you have any questions regarding the integration of health and safety programs in your business, you can read our blog on integrating OSH management into the overall business management system.

For more information on machine safety, you can consult our various blogs on this subject such as the classification of hazards areas, adding guards with padlocks and others or contact us. Our team of professionals will be glad to answer all of your questions and guide you in your efforts.

You can also follow our training courses on lockout and control of hazardous energies and machine safety: risk analysis and reduction.



Duguay, P., Busque, M.-A., Prud’homme, P. (2016). Évolution des lésions professionnelles – Indicateurs annuels 2007 à 2012. IRSST, DS-015. En ligne :

CNESST (2019). Honorons la mémoire des personnes décédées ou blessées au travail. Communiqué du 26 avril 2019. En ligne :

CNESST (2018). Accident mortel survenu le 5 décembre 2017 à un travailleur de l’entreprise 6835031 inc.. CNESST, Rapport d’enquête EN004189. En ligne :

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Intervention Prévention concentrates its operations in the field of work safety, offering specialized services following Standards CSA Z462 – Workplace Electrical Safety, CSA Z460 – Control of Hazardous Energy: Lock-out and Other Methods, and CSA Z432 – Safeguarding of Machinery.


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