But he couldn’t reach the drive motor. He stood on the edge of a hopper while another worker gained access using a ladder propped against the hopper on the opposite side of the platform.
After the repair was completed, they saw that dust and debris had fallen into the hopper.
As the man’s lower body lay across the edge of the hopper, with his legs sticking out across the platform, he leaned over and cleaned it.
At the same time, another worker turned the machine on.
His thumb, index and middle fingers were drawn in and crushed in the machine.
A diagram of the machine shows a pair of counterrotating, triangular-shaped rotors located at the base of the hopper (3), in which the victim’s hand was caught. Photo / Supplied
One of several people who witnessed the incident claimed staff had questioned the man’s competency with management before the incident, but nothing was done.
The person, who asked not to be named, told NZME they had worked alongside the victim for several months.
They had raised concerns with bosses in the months leading up to the incident and said the commercial bakery, which employs about 150 people, needed proper induction and training for technical staff.
But new employees were often put straight on the factory floor with little training, they said.
“The bakery needs to look after them and give staff proper training.
“He [the victim] was out of his depth; he didn’t know what he was doing; they knew he wasn’t up to standard.”
WorkSafe recently prosecuted the company in the Christchurch District Court for the incident.
It was fined $200,000 and ordered to pay $45,500 to the victim, who has permanent name suppression.
In a written statement, the victim said the incident had shattered his livelihood and destabilised his family’s future.
He said he had been left with permanent emotional and physical wounds.
Bakery owner apologises
French Bakery owner Gary Barber declined NZME’s request for an interview but provided a written statement, in which he acknowledged the court’s ruling.
“We sincerely regret the injuries suffered and have taken significant steps to ensure that no other employee is injured in the future.”
The stocking hopper, in red, and add-on platform, in blue, where the incident occurred. The machine’s drive motor, circled, which shows it cannot be easily accessed from the add-on platform. Photo / Supplied
A WorkSafe spokesperson said the victim’s life-changing injuries had exposed fundamental safety failures.
They said WorkSafe had identified repeated machinery safety and process-safety risks across multiple projects and routine assessments at the bakery throughout the years.
Inspectors had consistently assessed the level of harm, the likelihood of it recurring, and the attitude and capability of the business, the spokesperson said.
“Enforcement steps have been taken only where they were necessary to manage risk and support compliance.
“In line with the enforcement decision‑making model, improvement notices were issued when there was a clear gap between what the law requires and what was happening on site.
“Inspectors escalated their response when required, and the company was provided with best practice guidance to reinforce expectations around machinery safety.”
A history of health and safety issues
WorkSafe’s summary of facts showed the bakery had been issued with multiple improvement notices before the incident, three of which related to inadequately guarded machinery and two to hazardous substances.
There had also been seven notifiable incidents, and the bakery had received a written warning for failing to notify WorkSafe of a workplace incident, according to the summary.
Further inquiries into the bakery’s history showed multiple incidents in which workers have been injured, dating back to March 2016 when a person’s fingers were slightly crushed.
A month later, a worker’s hand was jammed between racks.
In June 2016, a worker’s fingers needed stitches after a machine cover fell on their hand.
There were also reported injuries in 2018, 2020 and 2022.
Other health and safety issues have been identified as dating back to June 2009, when a complaint alleged an emergency stop had been removed from a machine.
However, a subsequent site visit found the stop had been fitted.
A follow-up assessment in August 2009 identified several issues, including no systems for identifying, reviewing and controlling hazards, no health and safety committee, no system for recording and notifying incidents, untrained forklift operators and inadequately guarded machinery.
Meanwhile, another assessment in September 2013 resulted in three improvement notices being issued for inadequately guarding machines.
The bowl lifting machine located in the fenced area immediately behind the hopper. The machine’s drive motor assembly (circled) is located at the top of the add-on access platform behind the hopper. Photo / Supplied
More improvement notices followed in November 2019 after the company was found to be without a hazardous substances inventory and documented chemical-handling training.
In March 2024, two further improvement notices were issued for various issues.
Investigation into victim’s incident
A WorkSafe investigation into the 2023 finger-crushing incident found the bakery failed to ensure the hopper was inoperative before maintenance work was carried out.
The hopper’s selector switch used to start the machine couldn’t be secured or locked out.
Inspectors observed that other selector switches used to start machinery were capable of being secured with a lock-out padlock or a device, but there were no such devices available.
Barber produced a set of new, unused lock-out tags to inspectors after they attended the site following the 2023 incident.
The investigation showed the victim had never seen a lock-out tag used before the incident.
While he was an experienced engineer, his manager observed that he lacked some practical skills necessary for the role.
The manager had stopped allocating jobs to him, but no records showed that it had been communicated to others responsible for organising maintenance.
The worker had not read the manufacturer’s manuals for the hopper before the incident, while none of the workers had seen lock-out tags used before.
WorkSafe found the workers were exposed to a crushing hazard when cleaning the hopper, in particular, the counter-rotating dividing rollers located inside it.
There was also a risk of a fall from height as the hopper was 2.75m above the bakery floor.
Al Williams is an Open Justice reporter for the New Zealand Herald, based in Christchurch. He has worked in daily and community titles in New Zealand and overseas for the last 16 years. Most recently he was editor of the Hauraki-Coromandel Post, based in Whangamatā. He was previously deputy editor of the Cook Islands News.