Machinery safety remains one of the most common, and most preventable, causes of serious workplace injury. A recent HSE prosecution is a stark reminder of what happens when guarding and risk assessment fall short, particularly during cleaning and maintenance activities that fall outside normal production. This newsletter examines the case, what went wrong, and the key lessons for employers.
The Incident
Reflex Flexible Packaging Limited has been fined for the second time in under a year after a worker suffered a severe crush injury at its Telford site.
On 17 January 2025, a laminator operative and shift supervisor was cleaning the rollers of a laminating machine using rags after a production run. A rag became caught between two in-running rollers, pulling the worker’s left hand into the nip point up to the wrist. A colleague activated the emergency stop, allowing the worker to be freed. They were hospitalised, underwent two operations, spent four nights in hospital, and required physiotherapy to rebuild strength in the hand.
This followed a fatal incident at the company’s Langley Mill site in Derbyshire, for which Reflex was sentenced in November 2025 after an employee died when he became trapped in an unguarded machine.
What the HSE Investigation Found
The HSE investigation identified several failings:
- No fixed guard was in place to prevent access to the in-running nip point between the rollers during cleaning.
- The risk assessment was not suitable and sufficient, the cleaning operation itself had not been properly assessed, and the risk of a worker being drawn into the machine had not been identified.
- The safe system of work failed to provide clear instructions on using the foot pedal to rotate the rollers safely during cleaning.
Reflex Flexible Packaging Limited was fined £60,000 and ordered to pay £4,464 in costs at Birmingham Magistrates’ Court on 10 August 2026.
HSE Inspector Zach Morris commented:
“This incident was entirely preventable… Dutyholders should not focus solely on normal machine operation when considering access to dangerous parts. They must also consider activities such as cleaning, maintenance, and repair where workers may be exposed to dangerous parts of machinery that are inaccessible during normal operations.”
The Key Lesson: Look Beyond Normal Operation
This case highlights a recurring theme in machinery-related enforcement: guarding that’s adequate during production can still leave workers exposed during cleaning, maintenance, or repair, precisely when dangerous parts become accessible.
Under the Provision and Use of Work Equipment Regulations 1998 (PUWER), employers must take effective measures to prevent access to dangerous parts of machinery, following the hierarchy of control measures and giving priority to engineering controls such as fixed guarding wherever reasonably practicable.
Risk assessments must go further than assessing normal production activity. They need to explicitly consider:
- Cleaning and washdown procedures
- Maintenance and repair tasks
- Any point at which interlocks, guards, or isolation procedures might be bypassed or removed
- Clear, documented instructions for controlling machine movement (e.g. foot pedals, jog controls) during non-standard operations
A repeat enforcement action against the same company, following a fatality at one site and a serious injury at another, also underlines the importance of applying lessons learned consistently across all sites in an organisation, not just the one where an incident occurred.