Investigation of a workplace accident
I was asked to investigate a serious workplace accident at a packaging line in a food industry plant. The investigation began with an on-site inspection, a review of machine documentation, risk assessment and shift logs, followed by interviews with colleagues working on the shift.
Beyond the immediate cause — a bypassed safety device — the investigation also revealed that bypassing was not a one-off event but a tacitly tolerated practice during product changeovers. Behind the technical deficiency stood an organisational and leadership issue: the time allowed for changeovers was not sufficient for a compliant setup.
The expert opinion therefore went beyond establishing liability: it included an action plan to strengthen technical protection, redesign the changeover process and define a management control regime. The client took steps in all three areas.