It’s Friday afternoon at a factory manufacturing white goods components in Godmanchester. Two young Lithuanian women chat in the break area at RGE Engineering. Perhaps boyfriends, tonight’s plans or the next trip home to see mum and dad − mulled over in-between nibbles of biscuit and sips of tea. Except Zydre Groblyte, 23, will never be seeing her family again.
Minutes later Zydre’s head is smashed forward into the inking table of a printing machine. Ink pads plough down to pick up a printing image and pummel through flesh and bone instead. A thud, a crack, then a scream − and Zydre is gone.
“All of our fatality cases are depressing, but there was something particularly tragic about Zydre’s death,” reflects HSE case inspector, Stephen Faulkner of the fatality on 27 April, 2012. “Ultimately, preventing the accident was an easy fix.”
RGE Engineering said it was "deeply shaken" by the accident and has focused on enhancing safety (see p17). "Zydre's death was a tragedy that could and should have been avoided," the company stressed.
That’s why Works Management felt compelled to bring the case to your attention: to ensure it never happens again. Zydre’s death was enabled by lacklustre machine guarding and inadequate safety awareness, according to HSE.
“It’s a very big factory with around 100 injection moulding machines making components for white goods,” Faulkner says. Zydre was one of 50-150 agency workers site brought to work at the site daily at the time of the accident, according to Faulkner. She was bright, fluent in English and, in six months, had impressed supervisors. On minimum wage with limited training, she was put in charge of a printing machine and tasked with training another agency worker on the job.
The fatal moments before the accident
At 2pm, Zydre and her friend walked away from the machine, which prints instructions onto a plastic component for a tumble dryer, for their tea break. The production run was going well and they leave the equipment on standby. About 20 minutes later, the two women return. “It was a hot day,” says Faulkner. “That causes the ink within the machine to dry quicker. What we believe happened was Zydre disappeared around the back of the machine and climbed over the guarding to apply ink thinner before they started back up. ”
Undetected, Zydre makes her way into the machine, which is about the size of a small van. She sits on a platform that the jig, which transports components, moves along. Zydre leans forwards to the printing table to squirt ink thinners into the pots located within. It was then that the machine started. “We don’t know exactly why,” says Faulkner. “Zydre may have shouted an instruction back and her colleague misunderstood it.”
A fatal sequence of events rapidly unfolds. The machine powers up and its ink pads shoot around towards the inking table where they would normally pick up the stereo plate. Zydre has her back to the pads and is knocked forwards into the inking table.
Faulkner says: “The pathologist said there was trauma across her breast bone from the force of the machine pulling her down onto the table. The pad then comes down to ink and crushes her head. We were shocked by what the machine did.”
The scene played out to the unimaginable horror of her watching colleague. “She didn’t speak English so the only person she’d been able to communicate with in the factory is Zydre. One minute they’re out having a nice chat about what they’re going to do in the evening, and then she comes back and sees her friend nearly decapitated.”
Police arrive on the accident scene later that afternoon and are followed by Faulkner and fellow HSE inspector, Peter Burns (now deceased). It’s not long before the inspectors begin to spot some worrying safety oversights. “The moment we got there we knew it was wrong,” says Faulkner. “What you can see straight away is there’s a hole in that guard. We thought immediately 'we’ve got a PUWER reg 11 case here'.”
PUWER, or the Provision and Use of Work Equipment Regulations 1998 (see www.hse.gov.uk/pubns/books/l22.htm), set out what employers must do to safeguard workers using equipment in the workplace. The regulations cover everything from CNC machines to forklifts. PUWER stipulates an employer’s duty to ensure equipment is: suitable for use, properly maintained and regularly inspected.
Section 11 of PUWER compels employers to ‘take effective measures to prevent access or stop their movement before any part of a person enters a danger zone’. The ease of Zydre’s transit into the printing machine immediately troubles the HSE inspection team. Faulkner explains: “While the machine had a 1.5m fence at the front, at the back of the machine it was 0.9m − low enough to climb over, and there was a gap in there you can squeeze through. The police inspector on the scene got through in full body armour. Zydre was tall and slender, she could easily have got through or vaulted over the fence.”
The printing machine was equipped with an interlocked gate, the HSE inspector adds. But, once that gate shut, or an individual bypassed it via the gap or vaulting the fence, there was no lockout system to prevent the machine powering back up. “You could shut the gate and operate the machine using a mobile control panel inside the danger zone, which is fundamentally wrong,” says Faulkner.
Yet, manufacturing managers at RGE Engineering, Godmanchester, at the time, didn’t see the danger. Their oversight was symptomatic of a safety blindspot that can afflict businesses, explains Faulkner. "All the way up the management chain, we had people who’d only ever worked in that organisation and come to accept that way of working.”
That disconnect also showed in the site's approach to agency workers, adds Faulkner. “Workers like Zydre were coming in from their agency and being moved around the factory, there was no identification of their capabilities. Once you start sending someone inside complex machinery then I want to see a greater level of understanding.”
The HSE launched a prosecution against RGE Engineering in December 2015 for a breach of Regulation 11(1) of PUWER. But, an anomaly meant, despite its large size, RGE Engineering was not a Limited company at the time of the accident. Instead, the firm’s MD, Gordon Leach was registered as the legal employer and would find himself in the dock.
“He was genuinely sorry,” Faulkner says of Leach during the ensuing trial. “You hear that a lot, but it was very obvious. He conducted himself with dignity, was very co-operative and he was genuinely shocked too. It shook the whole factory to pieces, they all knew Zydre.”
The safety flaws that had contributed to her death were systemic rather than individual, stresses Faulkner. Leach had employed a health and safety officer with responsibility to ensure safety standards. Faulkner says: “The failure was a corporate one. People weren't doing their jobs properly throughout the management structure and on the shopfloor. But, because of the unusual duty holder status for such a large company. This has left a pensioner with the threat of prison.”
In February 2016, Leach pleaded guilty to breaching PUWER reg 11 (1) at Peterborough Crown Court. He received a 15-month sentence suspended for 24 months.
Zydre's' legacy: how RGE has improved safety on site
Meanwhile, back on site− RGE responded with an immediate and comprehensive health and safety review, including all risk assessments.
HSE improvement notices were met. The company also made changes to policy towards agency workers. RGE said: "Agency workers always underwent a rigorous training period before starting work. This has been continued and evolved to cover all aspects of workers' health and safety and safe working systems."
On the shopfloor, guarding has been improved to comply with PUWER. RGE said: "There were many machines at RGE, of which all but two (the machine in which the accident occurred and its sister machine) were guarded in compliance with regulation 11... All machine guarding is in place and is rigorously monitored and checked for compliance."
The material change has been supplemented by a cultural shift. All supervisors are trained to NEBOSH health and safety standards and work alongside two full-time health and safety officers, the firm said.
"Health and safety has to be the absolute number one priority in the business. In all of our senior management meetings and all day-to-day meetings health and safety issues, compliance and performance are the first topic on the agenda."
Asked to describe the legacy of Zydre's death, RGE responded: "Her death has led to all round improvements in health and safety at RGE and a safer working environment from all."
A ray of light at the end of a harrowing tale. One that should bring renewed focus to all, on attaining a high safety culture. For a serious accident could be just one lapse away. HSE figures show 27 manufacturing workers killed last year. A cloak and scythe still stalk the factory floor. Don’t let it happen on your site, on your watch. ■
Have a view on this story? email max.gosney@markallengroup.com
