International
Labour Organization

Your health and safety at work

CONTROLLING HAZARDS

Factors that caused the accident

1. Lack of machine guard

Effective engineering controls would have saved Juan Espinosa's life. Effective engineering controls could have included an enclosure guard around the pinch-point, and/or an interlocking guard to automatically stop the machine when the worker entered the danger zone.

2. Lack of training for a new worker

Normally workers were given 30 days of training before working on the steel slitter. Juan Espinosa was not given any training at all before he was assigned to a particularly dangerous job. He should have received 30 days of training and proper supervision once he started to work on the slitter.

3. Language barrier

Juan Espinosa was assigned to work under the supervision of John Doe on his first night on the job. The workers did not speak the same language. The senior worker, who was supervising Espinosa, could not instruct the new worker properly or warn him about dangers. Clear communication during training periods is essential for safety in any workplace. This can be accomplished by making sure training is in a language and at a level the worker(s) can understand.

4. Use of cardboard

Allowing workers to use cardboard to make the steel taut increased their risk of injury. Although workers should have used the tension stand, the employer encouraged the use of cardboard because it was quicker and more economical. The employer should have required use of the tension stand for safety.

5. Lack of company safety policies

The company did not have a safety policy prohibiting the use of unguarded machines. The employer should have had such a policy because unguarded machines make a workplace unsafe for everyone. Safety committees should work to develop these (and other) policies.

6. Lack of management commitment to safety

If the health and safety committee had been more effective, it could have taken action to make it impossible to operate an unguarded steel slitter. It could have pressured the employer to fit the machine with an appropriate guard. A health and safety committee should meet more often than every three months in order to recognize hazards regularly. To be effective, a health and safety committee should make frequent inspections in the workplace and should communicate the content of regular safety meetings to the workers.