The Provision and Use of Work Equipment Regulations 1998 (PUWER) are a line between people going home safe and never going home at all. Two recent HSE prosecutions outlined in this article show how basic failures to guard machinery and manage risk led directly to preventable deaths.
Both cases involve unguarded dangerous parts, known defects, and missed opportunities to act. They are about basics that every organisation using machinery should already control.
PUWER
PUWER places duties on anyone who owns, operates or controls work equipment, and on businesses whose employees use it, whether they own it or not.
In practice, it requires that work equipment is:
- Suitable for the task and environment
- Safe for use and properly maintained and inspected
- Used by competent people with adequate information, instruction and training
- Guarded or otherwise controlled so that dangerous parts cannot harm people
Regulation 11 is central in both these cases. Employers must prevent access to dangerous parts of machinery or stop their movement before anyone can reach the danger zone. Fixed guards are the default where access is needed, interlocked or other protective devices must give equivalent protection.
Case 1: Reflex Flexible Packaging
In May 2020, 46-year-old Paul Whalley was working at Reflex Flexible Packaging’s factory in Langley Mill, Derbyshire. He entered an opening in the side of a plastic conversion machine that allowed whole-body access to its moving parts. Inside, there were several unguarded mechanisms. He became trapped in the machine and, despite efforts by emergency services who cut belts and rollers to reach him, he died at the scene from crush asphyxia.
HSE found that the company had:
- No suitable and sufficient risk assessment for operation of the machine
- Failed to install appropriate guarding to prevent access to dangerous parts
- No written safe systems of work or isolation procedures
Internal health and safety staff had already identified a lack of risk assessments 18 months before the accident, but no effective follow-up action was taken.
The HSE inspector described it as a wholly avoidable incident that wouldn’t have occurred had the company fitted suitable guards.
Case 2: Bell Mount Farming
In January 2023, 61-year-old Alban Watts was working alone in a poultry shed for Bell Mount Farming Limited in Cumbria. A hen feeding system in the shed operated for short periods throughout the day. During one of these cycles, his clothing became entangled on an exposed rotating sprocket that powered the feeding system. He was strangled and died at the scene.
HSE’s investigation found that:
- The company had failed to prevent access to dangerous parts of the machinery.
- A guard designed to stop access to this sprocket was not fixed in place and could be lifted off.
- The bolt holes on the guard were stripped and misaligned with the frame, meaning it could not be secured properly.
In conclusion, a guard that should have been fixed with simple fasteners was effectively cosmetic. The family’s comment that his life was worth less than “the cost of a 50 pence screw” reflects just how basic this failure was.
Lessons from these two cases
Although the sectors and machinery were different, the themes are almost identical.
Unguarded or inadequately guarded dangerous parts
- Whole-body access in the plastics case; an exposed sprocket in the farming case.
- In both, PUWER Regulation 11’s core requirement to prevent access to dangerous parts was not met.
Weak or missing PUWER risk assessments
- In the plastics case there was no suitable and sufficient assessment for the machine, despite earlier internal warnings.
- In the farming case the condition and fixity of the guard were clearly not being monitored as part of an effective risk-based inspection and maintenance regime.
No robust safe systems of work and isolation
- Workers were able to enter or work close to danger zones while machinery could still operate.
- Documented procedures for isolation, lock-off and safe access either did not exist or were not implemented.
These two cases are prime examples of the type of failures PUWER and HSE’s Safe use of work equipment guidance are designed to prevent.
Practical steps for health & safety managers today
You cannot change these cases, but you can use them to sharpen your own PUWER controls. Some immediate, practical actions:
1. Re-check your high-risk machinery against PUWER
Focus on equipment with moving parts that can entangle, crush, draw in or shear. Review PUWER assessments to ensure they are machine-specific, cover all modes of operation and clearly identify guarding and isolation requirements.
2. Physically inspect guards and how they are fixed
Do a line walk with engineering and operators and ask:
- Can anyone reach dangerous parts, step into them or get pulled towards them?
- Are there openings large enough for hands, arms or whole bodies?
- Are guards secure, or can they be lifted, swung or removed without tools when they should be fixed?
3. Tighten your isolation and lock-off arrangements
No one should be entering the danger zone of machinery unless all sources of energy are isolated, locked off and verified. Standardise isolation points, use lock-out/tag-out, and consider interlocked access gates or trapped-key systems where people must enter enclosures.
4. Put safe systems of work in writing and make them live and accessible
For tasks like clearing blockages, cleaning inside guards or adjusting feeds, create clear, visual procedures and train against them.
Ensure workers know that bypassing a guard or entering equipment without isolation is never acceptable, even “just for a minute”.
5. Close the loop on findings and defects
Treat internal audits, near-miss reports and observed defects on guards as urgent PUWER issues.
Assign actions, track them to completion and escalate anything overdue. If a guard can’t be fixed properly, the equipment should not be used until it is.
These prosecutions sit within a long history of machinery incidents where the underlying message is the same: guard the danger, or people will get hurt.
A final question:
If an inspector, a coroner or a grieving family looked at your machinery today, could you show that guarding, isolation and safe systems of work are truly non-negotiable?
