Serious crushing injuries in packaging machinery

Removed safety barriers

Palletising machines are equipped with safety barriers designed to ensure they stop if personnel enter the restricted area surrounding the machine. One of the barriers is a safety fence around the machine, with doors that must remain closed during operation.

When one of the doors is opened, the machine's operating voltage is intended to be automatically disconnected.

In the incident on which this article is based, involving a palletising machine on board a vessel, two doors had been removed. This was justified on the grounds that the doors caused frequent stoppages during periods of good fishing and high activity in the factory.

The doors were fitted with sensors that functioned as safety devices. As a result, the operator was able to enter – and climb on to – the machine while it was still energised. The operator's movements activated sensors, which in turn activated the palletising machine while the person was inside it.

Following the incident, the NMA issued a safety notice: Use of palletising machines and other automated equipment on board.

Safe workplace

In the NMA's work on the national plan for maritime safety (the Vision Zero Initiative), safe workplace is a designated focus area. This is because many fatal accidents over the past ten years can be linked to individuals being in exposed positions. These are areas with multiple potential hazards, such as moving equipment, rotating machinery or falling loads.

Safety equipment that is not sufficiently adapted to the working conditions has contributed to fatal accidents. The absence of physical barriers also increases the risk of serious accidents. At the same time, the industry is highly dependent on workers themselves being aware of the hazerds and on establishing and following procedures for safe working practices.

The incident referred to therefore highlights the importance of having adequate barriers in place when working in exposed positions, in order to prevent serious crushing injuries. 

Risk assessment

The risk assessment for the incident referred to stated that the area was secured with safety barriers and that entry into the area would cause the packaging machine to stop. This assessment, however, was based on the assumption that the doors were installed. Consequently, the risk assessment did not reflect how the work was actually carried out by the employees.

An updated risk assessment must reflect the actual risk. In this incident, it did not do so, as the doors were not in place.

It is essential that those involved in the operation participate in the development of procedures, which must be relevant and realistic to follow. Otherwise, procedures may be bypassed, which can have serious consequenses for employees who are not familiar with the specific safefty conditions associated with the operation in question.

If certain tasks are caried out safely but outside the established procedure, it is important that the procedure is updated accordingly and made known to everyone.

Safety procedures not always followed

If efficiency requirements are set too high, or if procedures are not aligned with reality, the shipping company must take responsibility and address these challenges. In the NMA's 2025 survey on maritime safety, it was revealed that efficiency requirements imposed by shipping companies and ship management may affect safety and lead to procedures in the safety management system not being followed.

More than 25 per cent of respondents (one in four) stated that efficiency requirements set by the shipping company meant that they sometimes had to breach safety procedures to complete their work. Approximately 30 per cent stated that they sometimes had to breach safety procedures to complete their work. This indicates that there are also factors other than efficiency requirements that play a role. These may, for example, relate to how relevant or practicable the procedures are perceived to be.

All parties must contribute to maintaining safety and make assessments that support efficiency without reducing safety. Relevant personnel must be involved in the development of procedures.

By removing the doors providing access to the packaging machine in the incident referred to in this article, a safety barrier was removed without being compensated for by new measures. Even though it may be natural and acceptable to seek increased efficiency, compensatory safety measures must nevertheless be implemented.

Corrective measures

In the safety notice linked earlier in this article, several general corrective measures are identified. The NMA recommends that the entire industry establish a practice of always assessing corrective measures when safety barriers are modified or removed.

This includes:

• a comprehensive review and risk identification for both normal operation and operational deviations
• approval from the manufacturer or supplier when changes are made to barrier and safety functions
• ensuring that procedures or routines are in place for the isolation of machinery and equipment before work is permitted to commence
• technical safety devices must not be removed or disabled
• removal of safety barriers requires compensating measures to ensure an equivalent level of safety
• ensuring that the crew receive correct and sufficient training and familiarisation, both for normal operation and in case of operational disturbances. This must form part of the vessel's safety management system.