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Manufacturing worker died after his head was crushed by machine, safety feature was bypassed: Coroner


SINGAPORE: The death of a worker at a manufacturing company, after his head was crushed by a machine, could have been avoided if safety measures had been complied with, a coroner's court has found.

In findings made available this week, State Coroner Adam Nakhoda ruled the death of 34-year-old Chinese national Sun Zaitao a work-related misadventure.

Mr Sun had died of extensive crush injuries to his head on Feb 11 last year, after leaning into a window of a cardboard processing machine to clear waste.

His head was caught by parts of the machine and his body was pulled in or fell into the machine. He was pronounced dead at the scene.

Mr Sun worked as a production fitter for AMB Packaging, a paper and cardboard container and box manufacturer with its premises at 17 Senoko Loop.

He was trained to operate the machine that killed him - called the Tai Yi TGF High Speed Flexo Printer Slotter Rotary Die-Cutter Inline with Folder Gluer machine.

The machine would process corrugated cardboard into cartons bearing a customer's designs by cutting, glueing, folding and stacking the cardboard.

Mr Sun was specifically tasked to operate the machine from November 2021.

The machine, purchased in May 2019, was several meters long and consisted of six machinery components.

There was a viewing window at the bundle stacker portion of the machine, where the machine stacked items.

The window was 0.9m in height and 0.8m in width and came equipped with an interlocking guard.

If the window was opened when the machine was being operated, the guard would work by cutting the electrical supply to the machine.

At about 4.20pm on Feb 11 last year, Mr Sun was seen on closed-circuit television footage extending his upper body through the window of the machine while it was operating.

The coroner said it was likely that he was attempting to clear cardboard waste that had built up when he leaned further into the machine to remove a sub-standard carton.

"It was likely that Mr Sun's head was then caught by the upward moving collection mechanism and was then trapped between the collection mechanism and the stationary pair of metal pieces," said the coroner.

His body then either fell or was pulled by the machine's moving parts into the bundle stacker area, where he was found dead.


After Mr Sun's death, the Ministry of Manpower (MOM) found that the interlocking guard had been tampered with. A key was kept inserted into a device by the window frame so that the window would remain open even when the machine was operating.

This bypass was put in place so that the machine could operate without interruption. Usually, cardboard waste would accumulate near the window, requiring the machine to be stopped so workers could remove the waste.

By bypassing the interlocking guard, a worker could remove the waste via the window without stopping the machine from operating.

MOM reviewed closed-circuit television footage and noted that Mr Sun and a printer supervisor were seen extending their upper body into the window five and 11 times respectively between January and February 2022.

The workers would perform this dangerous act to remove sub-standard cartons and clear cardboard waste by brushing them to the floor. A printer operator had observed these acts, MOM's investigations revealed.

After Mr Sun's death, a stop work order was issued and the company reinstalled the interlocking guard, ensuring it was functional.

The Workplace Health and Safety Council (WSH Council) issued an alert on Feb 21 last year to create awareness of the risk control measures to be taken to prevent a similar occurrence.

The recommended safety measures included: The installation of machine guards to protect workers from contact with exposed moving parts, safety devices such as presence sensors to be installed at machine hazard zones and the use of audio-visual warning devices which would indicate hazardous situations.

Mr Sun's brother said he intended to engage a lawyer in Singapore to manage Mr Sun's death, but did not raise any issues or concerns over the fatal incident.

The coroner said this was an accident that could have been avoided. The machine was equipped with a safety feature that would prevent workers from coming into contact with moving machinery parts.

He said it was made clear to Mr Sun and other workers that the window had to be kept closed when the machine was operating - a fact emphasised by a trainer from the maker of the machine.

If the interlocking guard had been working, the machine would have stopped operating when Mr Sun opened the window, allowing him to clear the waste without the hazard of being caught by moving parts.

Unfortunately, the evidence showed that the interlocking guard had been bypassed since September 2019, around the time that the machine was commissioned for use at the premises, said the coroner.

He urged stakeholders who operate similar machinery to implement the recommendations by the WSH Council to prevent similar accidents from occurring in the future.

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