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Inadvertent starts causing accidents
Journal of Occupational Accidents,
4 (1982)
165
165-170
Elsevier Scientific Publishing Company,Amsterdam-Printed
INADVERTENT
Veikko
STARTS
CAUSING
ACCIDENTS
Centre
of Finland,
inThe Netherlands
Rouhiainen
Technical
Research
Laboratory,
Box
656,
SF-33101
Occupational
Tampere
Safety
Engineering
10, Finland
ABSTRACT
The increasing use of automation in industrial production has in many cases reduced accidents. However, it has also caused new safetv problems such as inadvertent starting up of machines and production start is a starting event of a technical system systems. An inadvertent or a part of it, which produces an undesired function or movement. The study of inadvertent starts was based on accident reports of the 105 accidents caused by inadvertNational Board of Labour Protection. ent starts were treated in the research. The aim of the studv was to determine which factors and conditions brought about inadvertent starts in production systems. The study showed that the most problematical branches of industrv were the metal, timber, food production and paper industries. Presses, conveyors and guillotine shears were typical machines where several inadvertent starts had occurred. The most dangerous work phases were repairing conveyors. elimination of blockages and, in particular, The event triggering an inadvertent start was generally caused by a worker. Frequently the cause was a wrong or hazardous working method. The lack of communication between workers, or a "human error" also often had an effect on the accident sequence. In order to prevent inadvertent starts measures must always he made to ensure that the stopped system definably remains stopped. A safe method of preventing an inadvertent start is to disconnect the machine from its power sources and make sure that nobody can turn on the power.
INTRODUCTION
The many
increasing
cases
sometimes starts
accidents has,
difficult
of machines serious
few years
however,
to control.
caused
heavy
and many
production
systems.
problems
include
They
critical
has in
and monotonous
new safety
Such problems
and production
accidents
in industrial
and decreased
have
incidents
phases
which
are
inadvertent been during
the cause
of
the l.ast
in Finland.
An inadvertent part
use of automation
Automation
of work.
several
removed
start
of it, that produces
is a starting an undesired
event
of a technical
function
0376-6349/82/0000-0000/$02.75 0 1982 Elsevier Scientific
or
movement.
Publishing Company
system
or a
166
In order personnel
to prevent
need
situations. systems. lation
Designers
of safety
INTO
A study Safety
conditions The
STARTS
of inadvertent
starts
Laboratory
aim of the study
brought
research
Labour
about
liquids
The distribution machine
material
inate
accidents.
being
evident
the different
that most
of the inadvertent and clippers.
The
showed
The primary groups start most
causes
are shown caused
common
machine
worker.
in Table
by human causes
The
cause
often
had an effect
were
branches
40) of press of presses
the most
groups
of
and
occur
with
dangerous
accidents.
will
problematical and paper
are examined,
elim-
branches indus-
it can be seen
guillotine
task groups
of an operational
shears,
were working
obstruction
in con-
a conveyor.
If press
according
common
case
accidents are
the start
an inadvertent
between
starts
starts
touching
was frequently
lack of communication
of
industrial
and the handling
food production
of inadvertent
triggering
starts serious
to industrial
(about
1 that
2. The most
error.
Board
1. It can be seen that the
the working
for inadvertent
and accidentally
The event
The
as repairing
systems.
industries.
amount
starts
that the most
and the removal
as well
to vehicles
according
machine
from
of
and
of the National
by inadvertent
in Table
timber,
conveyors
presses
paid
Centre
factors
in production
reports
in process
from Table
tries.
veyors,
starts
was collected
concerning
are the metal,
with
to determine
caused
is shown
of industry
study
which
a considerable
regulations
When
control
and instal-
out at the Occupational Research
of accidents
groups
included
It is also
hazardous
complex
was
The data
materials
The present these
was carried
on accident
less attention
and gaseous
various
for designing
of the Technical
105 accidents
in the research.
accidents,
and maintenance
various
for the construction
inadvertent
was based
Protection.
treated
are also needed
INADVERTENT
The
operators
how to control
devices.
Engineering
Finland.
starts
about
need guide-lines
Guide-lines
RESEARCH
inadvertent
instructions
intentional
then
starting
was generally
or hazardous
workers,
on the accident
is an inadvertent
are omitted,
the a
button.
start
a wrong
to machine
or a "human
sequence.
caused
working error”
by a
method. alsO
Presses in machine shop Other presses Rollers, cylinders and others Saws and clipping machines Guillotine shears Crushing machines and pulverizers
0 0 0 4
0 2 39
11. Other branches of industry
0
0 32
0
10
3 0
0
0
1 13 0
0 0
0
4
10
0
2
0
0
0
10 0
0
0
3
4
0
0
0
0
0
0
4
0
0
4
9
110 2
3
0 3
10
0
0
0
0
0 0
0
7
0
0
0 0
0
0
2 1
0
0
10 0 1
0 10
2
6
0
5
5 6
0 0
8
14
15
105
7
4
0 1 1
1 0
31
0 0 0
3
0
0 0
0
0
0
3
26
7 0
1
5
2 0
1
1 0
0 2
0 11
4
0
0
11
3
10
10
0
0
-
0
2
0 2
0 9 2
0 1
0
9
0
8
Mixing machines for concrete Conveyors Other transferring and lifting machines Packaging machines Other machines
0
12
7. 8. 9. 10. 11.
9. Metal industry 10. Construction industry
7. Porcelain, ceramic and glass industry 8. Basic metal industry
5. Paper industry 6. Chemical industry
1. Agriculture and forestry 2. Food production industry 3. Leather, textile and clothing industry 4. Timber industry
INDUSTRIAL BRANCH
1. 2. 3. 4. 5. 6.
MACHINE GROUP
Table 1. Inadvertent starts according to branches of industry.
168 Table
2. Primary
Primary
of inadvertent
starts.
cause
Intentional Start
causes
Frequency
start
caused
Accidentally Intentionally
24
by human
error
touching
the start
touching
26 button
the boundary
Accidentally
touching
Start
caused
by the machine
the boundary itself
Start
caused
by the material
being
21
switch
1
switch
6 16
handled
5 6
Obscure
105
Total
The kind of injuries Ta:ble 3. A large
Table
number
3. Injuries
caused
caused
by the
of the
injuries
inadvertent were
by inadvertent
starts
are shown
starts.
Frequency
Injury Cut or contusion
18
Fracture
23
Loss of one or more Internal
34
fingers
7
injury
7
i3bscure
105
Total
PREVENTION
OF ACCIDENTS
The possibility when
in
very serious.
reason
two main groups:
methods
system must
The principles
procedures
procedures
In a maintenance
is not applicable ensuring
that
inadvertent
start
for repair,
situations. are
the working
in this case.
starts
to maintenance
operating
zone and therefore
the stoppage
by inadvertent
stopped
of both groups
situation
danger
STARTS
occurring
cleaning
or for
be considered.
applied
to normal
characteristic
caused
has been
always
of preventing
applied
the machine's
BY INADVERTENT
of an accident
the mechanical
some other
CAUSED
situations,
illustrated
in Fig.
object
very often access
should
into
and
The prevention
preventing
The system
is absolute.
can be divided
be made
1.
lies within
to the zone safe by
169
I
1'70 As machines
in industry
lem is to disconnect electric
current,
by fitting circuit,
is made
that nobody When sources
from
in a reliable
a safety
switch
by removing
machine
are usually
the motor
safe
driven
way.
or by taking
also
the prevention
of inadvertent
must
be considered,
such as hydraulics,
also
energy.
also cause
the hazard.
certain
out. When be done
the
to ensure
the machine.
designing
mechanical
the
or in the control
the plug must
the prob-
i.e. from
can be made
supply
in this way, measures
can restart
energy,
Disconnection
into the energy
the fuses
by electricity
its driving
The gases All
and liquids
starts,
escaping
such disconnections
other
energy
pneumatics
into
must
and
the system
can
be considered
in
the design. When connect must
a mechanical
or electrical
the machine
and powersource
check
operation
can be made
the off-position In a normal preventing
used
is opened.
that detect
siuation
the machine With
alien
objects
must
be constructed
on electrical
danger
used
zone with
in the danger
forces.
barriers.
They
by can
at all when
speeds,
zone
it in
can be avoided
not start
at slow
so that The
to keep
or spring
starts
or will
running
to dis-
the disconnection
it is disconnected.
or the means
stops
machines
is used
other,
inadvertent
to the machine's
so that
that
device
not depend
operating
access
be designed barrier
should
device
to ensure
of the disconnecting
or valve
from each
The disconnection
be reliable.
a visual
switch
devices
the
can be
and stop the machine
immediately. Starting devices when
alarms
relating
somebody
to inadvertent
starts
up. An emergency the machine
and emergency
stops
can be regarded
starts.
the machine,
but
stop can prevent
A starting
it does
or diminish
as precaution
alarm
gives
not prevent injuries,
a Signal
the starting
as it can stop
as soon as possible.
CONCLUSIONS
The nature starts
more
the cause involved
of accident
complicated
statistics
because
of the accidents. in an accident
makes
research
into
they are not classified
More
sequence
detailed would
classification
make
inadvertent according
to
of the factors
the use of statistics
more
effective. The prevention vices
which
Effective ensure
would
training
of inadvertent disconnect
starts
a system
in the prevention
that the measures
required
needs
reliable
technical
from all of its power procedures
is also
are in fact put
de-
sources.
needed
into practice.
to
4 (1982)
165
165-170
Elsevier Scientific Publishing Company,Amsterdam-Printed
INADVERTENT
Veikko
STARTS
CAUSING
ACCIDENTS
Centre
of Finland,
inThe Netherlands
Rouhiainen
Technical
Research
Laboratory,
Box
656,
SF-33101
Occupational
Tampere
Safety
Engineering
10, Finland
ABSTRACT
The increasing use of automation in industrial production has in many cases reduced accidents. However, it has also caused new safetv problems such as inadvertent starting up of machines and production start is a starting event of a technical system systems. An inadvertent or a part of it, which produces an undesired function or movement. The study of inadvertent starts was based on accident reports of the 105 accidents caused by inadvertNational Board of Labour Protection. ent starts were treated in the research. The aim of the studv was to determine which factors and conditions brought about inadvertent starts in production systems. The study showed that the most problematical branches of industrv were the metal, timber, food production and paper industries. Presses, conveyors and guillotine shears were typical machines where several inadvertent starts had occurred. The most dangerous work phases were repairing conveyors. elimination of blockages and, in particular, The event triggering an inadvertent start was generally caused by a worker. Frequently the cause was a wrong or hazardous working method. The lack of communication between workers, or a "human error" also often had an effect on the accident sequence. In order to prevent inadvertent starts measures must always he made to ensure that the stopped system definably remains stopped. A safe method of preventing an inadvertent start is to disconnect the machine from its power sources and make sure that nobody can turn on the power.
INTRODUCTION
The many
increasing
cases
sometimes starts
accidents has,
difficult
of machines serious
few years
however,
to control.
caused
heavy
and many
production
systems.
problems
include
They
critical
has in
and monotonous
new safety
Such problems
and production
accidents
in industrial
and decreased
have
incidents
phases
which
are
inadvertent been during
the cause
of
the l.ast
in Finland.
An inadvertent part
use of automation
Automation
of work.
several
removed
start
of it, that produces
is a starting an undesired
event
of a technical
function
0376-6349/82/0000-0000/$02.75 0 1982 Elsevier Scientific
or
movement.
Publishing Company
system
or a
166
In order personnel
to prevent
need
situations. systems. lation
Designers
of safety
INTO
A study Safety
conditions The
STARTS
of inadvertent
starts
Laboratory
aim of the study
brought
research
Labour
about
liquids
The distribution machine
material
inate
accidents.
being
evident
the different
that most
of the inadvertent and clippers.
The
showed
The primary groups start most
causes
are shown caused
common
machine
worker.
in Table
by human causes
The
cause
often
had an effect
were
branches
40) of press of presses
the most
groups
of
and
occur
with
dangerous
accidents.
will
problematical and paper
are examined,
elim-
branches indus-
it can be seen
guillotine
task groups
of an operational
shears,
were working
obstruction
in con-
a conveyor.
If press
according
common
case
accidents are
the start
an inadvertent
between
starts
starts
touching
was frequently
lack of communication
of
industrial
and the handling
food production
of inadvertent
triggering
starts serious
to industrial
(about
1 that
2. The most
error.
Board
1. It can be seen that the
the working
for inadvertent
and accidentally
The event
The
as repairing
systems.
industries.
amount
starts
that the most
and the removal
as well
to vehicles
according
machine
from
of
and
of the National
by inadvertent
in Table
timber,
conveyors
presses
paid
Centre
factors
in production
reports
in process
from Table
tries.
veyors,
starts
was collected
concerning
are the metal,
with
to determine
caused
is shown
of industry
study
which
a considerable
regulations
When
control
and instal-
out at the Occupational Research
of accidents
groups
included
It is also
hazardous
complex
was
The data
materials
The present these
was carried
on accident
less attention
and gaseous
various
for designing
of the Technical
105 accidents
in the research.
accidents,
and maintenance
various
for the construction
inadvertent
was based
Protection.
treated
are also needed
INADVERTENT
The
operators
how to control
devices.
Engineering
Finland.
starts
about
need guide-lines
Guide-lines
RESEARCH
inadvertent
instructions
intentional
then
starting
was generally
or hazardous
workers,
on the accident
is an inadvertent
are omitted,
the a
button.
start
a wrong
to machine
or a "human
sequence.
caused
working error”
by a
method. alsO
Presses in machine shop Other presses Rollers, cylinders and others Saws and clipping machines Guillotine shears Crushing machines and pulverizers
0 0 0 4
0 2 39
11. Other branches of industry
0
0 32
0
10
3 0
0
0
1 13 0
0 0
0
4
10
0
2
0
0
0
10 0
0
0
3
4
0
0
0
0
0
0
4
0
0
4
9
110 2
3
0 3
10
0
0
0
0
0 0
0
7
0
0
0 0
0
0
2 1
0
0
10 0 1
0 10
2
6
0
5
5 6
0 0
8
14
15
105
7
4
0 1 1
1 0
31
0 0 0
3
0
0 0
0
0
0
3
26
7 0
1
5
2 0
1
1 0
0 2
0 11
4
0
0
11
3
10
10
0
0
-
0
2
0 2
0 9 2
0 1
0
9
0
8
Mixing machines for concrete Conveyors Other transferring and lifting machines Packaging machines Other machines
0
12
7. 8. 9. 10. 11.
9. Metal industry 10. Construction industry
7. Porcelain, ceramic and glass industry 8. Basic metal industry
5. Paper industry 6. Chemical industry
1. Agriculture and forestry 2. Food production industry 3. Leather, textile and clothing industry 4. Timber industry
INDUSTRIAL BRANCH
1. 2. 3. 4. 5. 6.
MACHINE GROUP
Table 1. Inadvertent starts according to branches of industry.
168 Table
2. Primary
Primary
of inadvertent
starts.
cause
Intentional Start
causes
Frequency
start
caused
Accidentally Intentionally
24
by human
error
touching
the start
touching
26 button
the boundary
Accidentally
touching
Start
caused
by the machine
the boundary itself
Start
caused
by the material
being
21
switch
1
switch
6 16
handled
5 6
Obscure
105
Total
The kind of injuries Ta:ble 3. A large
Table
number
3. Injuries
caused
caused
by the
of the
injuries
inadvertent were
by inadvertent
starts
are shown
starts.
Frequency
Injury Cut or contusion
18
Fracture
23
Loss of one or more Internal
34
fingers
7
injury
7
i3bscure
105
Total
PREVENTION
OF ACCIDENTS
The possibility when
in
very serious.
reason
two main groups:
methods
system must
The principles
procedures
procedures
In a maintenance
is not applicable ensuring
that
inadvertent
start
for repair,
situations. are
the working
in this case.
starts
to maintenance
operating
zone and therefore
the stoppage
by inadvertent
stopped
of both groups
situation
danger
STARTS
occurring
cleaning
or for
be considered.
applied
to normal
characteristic
caused
has been
always
of preventing
applied
the machine's
BY INADVERTENT
of an accident
the mechanical
some other
CAUSED
situations,
illustrated
in Fig.
object
very often access
should
into
and
The prevention
preventing
The system
is absolute.
can be divided
be made
1.
lies within
to the zone safe by
169
I
1'70 As machines
in industry
lem is to disconnect electric
current,
by fitting circuit,
is made
that nobody When sources
from
in a reliable
a safety
switch
by removing
machine
are usually
the motor
safe
driven
way.
or by taking
also
the prevention
of inadvertent
must
be considered,
such as hydraulics,
also
energy.
also cause
the hazard.
certain
out. When be done
the
to ensure
the machine.
designing
mechanical
the
or in the control
the plug must
the prob-
i.e. from
can be made
supply
in this way, measures
can restart
energy,
Disconnection
into the energy
the fuses
by electricity
its driving
The gases All
and liquids
starts,
escaping
such disconnections
other
energy
pneumatics
into
must
and
the system
can
be considered
in
the design. When connect must
a mechanical
or electrical
the machine
and powersource
check
operation
can be made
the off-position In a normal preventing
used
is opened.
that detect
siuation
the machine With
alien
objects
must
be constructed
on electrical
danger
used
zone with
in the danger
forces.
barriers.
They
by can
at all when
speeds,
zone
it in
can be avoided
not start
at slow
so that The
to keep
or spring
starts
or will
running
to dis-
the disconnection
it is disconnected.
or the means
stops
machines
is used
other,
inadvertent
to the machine's
so that
that
device
not depend
operating
access
be designed barrier
should
device
to ensure
of the disconnecting
or valve
from each
The disconnection
be reliable.
a visual
switch
devices
the
can be
and stop the machine
immediately. Starting devices when
alarms
relating
somebody
to inadvertent
starts
up. An emergency the machine
and emergency
stops
can be regarded
starts.
the machine,
but
stop can prevent
A starting
it does
or diminish
as precaution
alarm
gives
not prevent injuries,
a Signal
the starting
as it can stop
as soon as possible.
CONCLUSIONS
The nature starts
more
the cause involved
of accident
complicated
statistics
because
of the accidents. in an accident
makes
research
into
they are not classified
More
sequence
detailed would
classification
make
inadvertent according
to
of the factors
the use of statistics
more
effective. The prevention vices
which
Effective ensure
would
training
of inadvertent disconnect
starts
a system
in the prevention
that the measures
required
needs
reliable
technical
from all of its power procedures
is also
are in fact put
de-
sources.
needed
into practice.
to