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A Zero Harm Program for Machine Safeguarding

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Australian Institute of Health & Safety
Australian Institute of Health & Safety

This document describes a zero harm machinery safeguarding program implemented by an international pharmaceutical manufacturer. It details a case study where the manufacturer had several serious machinery injuries between 2004-2009 due to unguarded hazards and deficiencies in risk assessments. In response, the company developed a 5-day "Zero Access" training program to systematically identify and document all access points to hazards. The program was piloted at 10 sites across 9 countries. Key findings included numerous guarding deficiencies and issues with machine intervention practices. Monitoring found that physical access posed a larger problem than interlock deficiencies. Sustaining the program required reassessments, effective training, and continued monitoring.

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“Zero Access” A Zero Harm Program for Machine Safeguarding Case study of an international program. Andrea Rowe, Safety Action Pty Ltd andrea@safetyaction.com.au
Overview • Background • Case Study: – Zero Access Pilot Program – Rollout – Monitoring – Sustaining • Findings and lessons.
Case Study #1: Pharmaceutical Manufacturer • Several serious machinery injuries (world-wide) 2004-2009; • 90% injuries involved operators; • Class-room training & risk assessments; • Personnel did not understand the extent and integrity of guarding required; • Risk assessments and inspections continually failed to detect the deficiencies; • Company vision of Zero Harm.
Why don’t checklists work? • Not systematic; • Do not consider all access points; • Form not designed to document many hazards; • Unclear documentation; • Difficult to implement solutions. More info: See my ZERO ACCESS paper online
Qld Manufacturing fixed plant tool
International company tool • Single line for each equipment
Local assessment tool
Zero Access Program- Pilot ➢ Safety Action developed 5-day program; ➢ 10 sites across 9 countries ➢ Skill users in Zero Access standards & RA process. Note: Photos from various international manufacturers. Not from GSK.
No Access Required Work, but No Energy Required Reach-In Interlock Guard Whole Body Entry (some energy) Work, but Some Energy Required Zero Access Guarding LOTO Isolation Procedure Interlocks Stop & Lock to Prevent Re-Start Non- LOTO Procedure Overview of Machinery Safeguarding PrimarySafetySystem Normal Operation Machinery Intervention Required 0 1 2 43
Zero Access Principles 1. No operator can touch harmful machine parts. (Intentionally or Unintentionally) 2. To find all problems you have to assume they are there, until proven safe 3. Rules and behaviour do not give zero access 4. To be a guard it must require a tool to remove it or be interlocked
Zero Access Principles 6. Interlocks must be adjusted to prevent access until safe 7. Physical access is a bigger problem than interlock category 7. Interlock maintenance & adjustment is more important than interlock category 8. Not all moving parts, holes or unsecured doors pose a hazard.
Zero Access Method: Documenting Hazards
Method • Blank page/ simple record form; • Systematic approach, start to end production line/ machine; • Find access points; • Measure gap- finger, hand, arm, body? • Distance to hazard? • Summary AS4024 guidance.
Company, site Zero Access Assessment Worksheet Department: Plant ID / Line: Date Assessed: Item No. Hazard Initial Risk Existing Controls Existing Controls OK Yes / No Action Plan (if No) Final Risk Level Photo Ref. Likeli- hood Seve rity Risk Level Assessed By: Consulted with: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . & local personnel as available on day Note: Risk levels per agreed Risk Matrix (supplied) Zero Access Assessment - Worksheet
Principles- Based on AS4024 Key Principles for Machine Guarding 1. Unguarded hazards on top of machinery must be out of reach e.g. at least 2.7m from floor. 2. Safety fences to be at least 1.6m high (no foot holds), or RA to prove lower is safe. At least 900mm if electronic curtain or eye beams. 3. Gaps under safety fences or barriers to be < 180mm to prevent person access. If electronic curtain or eye beams, gap under < 300mm. 4. If aperture capable of (e.g. per EN and ISO and AS 4024.1801&2);    a) Finger-tip entry (gap 2mm to 6mm) then hazards must be > 10mm away.  b) Finger access (gap 6mm to 12mm) then hazards must be > 100mm away.  c) Hand access (gap 12mm to 20mm) then hazard must be > 120mm away.  d) Arm entry (gap 20mm to 120mm) then hazards must be > 850mm away e.g. arms reach.  e) Leg entry (gap 95mm to 180mm) then hazards must be > 1.1m away.  f) Person gaining entry (gap > 180mm) then reduce gap < 180mm or install tunnel e.g. provide tunnel over in-feed or out-feed conveyors. 
Zero Access tools
What/ where could this hazard be?
Long shot showing location of hazard. Close up photo of specific hazard
Key Findings 1. There are usually deficiencies in; a) Machine guarding e.g. 40+ hazards per typical packaging line. b) Machine intervention practices. Types of Hazards Identified Percentages (rounded off) Guard or panel not secured in place or unlocked 20% Access around, under or over or hazard not guarded 50% Interlock deficiencies 10% Other including; labelling of controls, fall off machine, electrical hazard etc 20%
3. Maintenance & inspection important to sustain; 4. Don’t rely on CE Mark; 5. New equipment safer but not fully compliant - installation & change management important. Key Findings
6. Physical access is a bigger problem than interlock category; 7. Interlock adjustment more important than category level; 8. Cultural differences (1.5 meter rule) Key Findings
0 1 2 3 4 People and resources Leadership and Governance Risk assessment Controls Management Responding to problems Site Machinery Safety Maturity Level Site 27 19 8 0 5 10 15 20 25 30 Total # of LOTO exceptions LOTO exceptions controlled with SSoW LOTO exceptions controlled with PTW Site LOTO Exceptions 8 11 43 Site MS Open Risks Red Amber Green Monitoring Zero Access
Sustaining Zero Access Re-assessment 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentages 2016 (%) Percentages 2009 (%) Machinery Safety Risk Assessments 2009 vs. 2016 Melbourne, Australia Green Low Amber Medium Orange/ red High/ very high
How to design an effective MS training program? • Simple tools; • Min. 2 days practical shop-floor training & recording; • LOTO, interlocks etc, non-LOTO; • Solutions guidance e.g. common problems, workshop equipment; • Monitor and sustain.
Further information- Contact me Ask for Key Principles Card or “monkey finger” Andrea Rowe Tassioulas General Manager Safety Action Pty Ltd ® T. 03 9690 6311 M. 0411 703 906 International: +61 3 9690 6311 E. andrea@safetyaction.com.au

More Related Content

A Zero Harm Program for Machine Safeguarding

  • 1. “Zero Access” A Zero Harm Program for Machine Safeguarding Case study of an international program. Andrea Rowe, Safety Action Pty Ltd andrea@safetyaction.com.au
  • 2. Overview • Background • Case Study: – Zero Access Pilot Program – Rollout – Monitoring – Sustaining • Findings and lessons.
  • 3. Case Study #1: Pharmaceutical Manufacturer • Several serious machinery injuries (world-wide) 2004-2009; • 90% injuries involved operators; • Class-room training & risk assessments; • Personnel did not understand the extent and integrity of guarding required; • Risk assessments and inspections continually failed to detect the deficiencies; • Company vision of Zero Harm.
  • 4. Why don’t checklists work? • Not systematic; • Do not consider all access points; • Form not designed to document many hazards; • Unclear documentation; • Difficult to implement solutions. More info: See my ZERO ACCESS paper online
  • 6. International company tool • Single line for each equipment
  • 8. Zero Access Program- Pilot ➢ Safety Action developed 5-day program; ➢ 10 sites across 9 countries ➢ Skill users in Zero Access standards & RA process. Note: Photos from various international manufacturers. Not from GSK.
  • 9. No Access Required Work, but No Energy Required Reach-In Interlock Guard Whole Body Entry (some energy) Work, but Some Energy Required Zero Access Guarding LOTO Isolation Procedure Interlocks Stop & Lock to Prevent Re-Start Non- LOTO Procedure Overview of Machinery Safeguarding PrimarySafetySystem Normal Operation Machinery Intervention Required 0 1 2 43
  • 10. Zero Access Principles 1. No operator can touch harmful machine parts. (Intentionally or Unintentionally) 2. To find all problems you have to assume they are there, until proven safe 3. Rules and behaviour do not give zero access 4. To be a guard it must require a tool to remove it or be interlocked
  • 11. Zero Access Principles 6. Interlocks must be adjusted to prevent access until safe 7. Physical access is a bigger problem than interlock category 7. Interlock maintenance & adjustment is more important than interlock category 8. Not all moving parts, holes or unsecured doors pose a hazard.
  • 13. Method • Blank page/ simple record form; • Systematic approach, start to end production line/ machine; • Find access points; • Measure gap- finger, hand, arm, body? • Distance to hazard? • Summary AS4024 guidance.
  • 14. Company, site Zero Access Assessment Worksheet Department: Plant ID / Line: Date Assessed: Item No. Hazard Initial Risk Existing Controls Existing Controls OK Yes / No Action Plan (if No) Final Risk Level Photo Ref. Likeli- hood Seve rity Risk Level Assessed By: Consulted with: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . & local personnel as available on day Note: Risk levels per agreed Risk Matrix (supplied) Zero Access Assessment - Worksheet
  • 15. Principles- Based on AS4024 Key Principles for Machine Guarding 1. Unguarded hazards on top of machinery must be out of reach e.g. at least 2.7m from floor. 2. Safety fences to be at least 1.6m high (no foot holds), or RA to prove lower is safe. At least 900mm if electronic curtain or eye beams. 3. Gaps under safety fences or barriers to be < 180mm to prevent person access. If electronic curtain or eye beams, gap under < 300mm. 4. If aperture capable of (e.g. per EN and ISO and AS 4024.1801&2);    a) Finger-tip entry (gap 2mm to 6mm) then hazards must be > 10mm away.  b) Finger access (gap 6mm to 12mm) then hazards must be > 100mm away.  c) Hand access (gap 12mm to 20mm) then hazard must be > 120mm away.  d) Arm entry (gap 20mm to 120mm) then hazards must be > 850mm away e.g. arms reach.  e) Leg entry (gap 95mm to 180mm) then hazards must be > 1.1m away.  f) Person gaining entry (gap > 180mm) then reduce gap < 180mm or install tunnel e.g. provide tunnel over in-feed or out-feed conveyors. 
  • 18. Long shot showing location of hazard. Close up photo of specific hazard
  • 19. Key Findings 1. There are usually deficiencies in; a) Machine guarding e.g. 40+ hazards per typical packaging line. b) Machine intervention practices. Types of Hazards Identified Percentages (rounded off) Guard or panel not secured in place or unlocked 20% Access around, under or over or hazard not guarded 50% Interlock deficiencies 10% Other including; labelling of controls, fall off machine, electrical hazard etc 20%
  • 20. 3. Maintenance & inspection important to sustain; 4. Don’t rely on CE Mark; 5. New equipment safer but not fully compliant - installation & change management important. Key Findings
  • 21. 6. Physical access is a bigger problem than interlock category; 7. Interlock adjustment more important than category level; 8. Cultural differences (1.5 meter rule) Key Findings
  • 22. 0 1 2 3 4 People and resources Leadership and Governance Risk assessment Controls Management Responding to problems Site Machinery Safety Maturity Level Site 27 19 8 0 5 10 15 20 25 30 Total # of LOTO exceptions LOTO exceptions controlled with SSoW LOTO exceptions controlled with PTW Site LOTO Exceptions 8 11 43 Site MS Open Risks Red Amber Green Monitoring Zero Access
  • 23. Sustaining Zero Access Re-assessment 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentages 2016 (%) Percentages 2009 (%) Machinery Safety Risk Assessments 2009 vs. 2016 Melbourne, Australia Green Low Amber Medium Orange/ red High/ very high
  • 24. How to design an effective MS training program? • Simple tools; • Min. 2 days practical shop-floor training & recording; • LOTO, interlocks etc, non-LOTO; • Solutions guidance e.g. common problems, workshop equipment; • Monitor and sustain.
  • 25. Further information- Contact me Ask for Key Principles Card or “monkey finger” Andrea Rowe Tassioulas General Manager Safety Action Pty Ltd ® T. 03 9690 6311 M. 0411 703 906 International: +61 3 9690 6311 E. andrea@safetyaction.com.au