Last year, an SMRT technician was operating a hydraulic press machine when a 2.9kg rod shot out of the machine and hit him in the face. The worker had later passed away.
On Tuesday (23 Mar), a coroner has ruled that 30-year-old Muhammad Afiq Senawi’s death was an “unfortunate misadventure”.
Coroner Christopher Goh found that there was no evidence of foul play and gave his deepest condolences to Afiq’s family and fiancee who were present in court.
Mr Afiq had worked at Bishan Depot’s rolling stock workshop, where trains and their components are maintained.
The Day of the Incident
On 23 March 2020, he was at work, operating the hydraulic press machine and was assigned a co-worker, Muhammad Halmie Hamidi. The two were supposed to take turns operating the machine, while the other acted as an assistant.
Mr Halmie had initially met a safety officer to discuss an earlier incident and later went to his workstation at around 9:00 am.
As Mr Afiq was already in front of the machine, he had assumed that his co-worker had already performed the necessary safety checks.
They were assigned with removing and installing components on a pallet containing rod arms, reported CNA. The installation of the first two arms went smoothly.
However, when Mr Afiq began operating the machine on the third rod arm, Mr Halmie noticed that a pad was not aligned properly and asked Mr Afiq to remove the part as it was damaged.
He looked away for a few seconds to see how many pallets were left and noticed Mr Afiq inserting a spacer rod into the machine. Mr Halmie was unsure of what he was doing but did not say anything as he thought that Mr Afiq knew what he was doing due to his experience.
When Mr Afiq pressed down on a piston, Mr Halmie realised that something was wrong as the piston was moving very slowly. He had told Mr Afiq to stop.
Mr Halmie looked away again to check the number of rod arms left when he heard the machine being operated, followed by a loud “bang”.
He jumped backwards in shock and saw Mr Afiq fell backwards. He was lying face up in front of the machine, gasping for air. A hole had been created in the gate meant to prevent workers from putting their hands in the machine.
Other colleagues rushed to perform cardiopulmonary resuscitation and called for an ambulance.
Another worker checked if Mr Afiq was choking as he did not respond to his name being called. Blood started gushing out of his mouth and the worker pulled his tongue out to prevent him from choking.
He was taken to Tan Tock Seng Hospital (TTSH) where he was pronounced dead at 11:00am on the same day.
The autopsy revealed that there was no foul play. He had sustained injuries on the lower part of his face, with a cut extending from his lip to his chin.
What Went Wrong
A Ministry of Manpower (MOM) investigations revealed that when Mr Afiq and Mr Halmie had placed the component into the hydraulic press machine and operated the piston, they forgot to remove the old component that was in the cavity.
This caused a build-up of pressure which forcefully ejected the steel rod.
The MOM officer also testified that while both workers were trained in the machine’s operation, certain details of operation processes were not in the work instructions.
More specifically, instructions did not state that the cavity had to be empty before performing the next step.
Risk assessments did find that components might fly out of the machine. However, SMRT did not anticipate that the steel rod would be a strong projectile.
Coroner Goh also notes that Mr Afiq and Mr Halmie were standing in front of the machine within the hazardous area, which was not properly marked out.
“There were safety measures in place, but it was regretful that this particular scenario did not seem to have been envisaged.”
No such incidents have occurred in more than two decades since the work processes were put in place in the 1980s.
MOM and SMRT’s Response
Measures have since been put in place to prevent such incidents from occurring again.
Immediately after the incident, MOM had issued a stop-work order and required SMRT to conduct a reassessment of the risks involved in the operating process.
The hazardous area in front of the hydraulic press machine has been marked out clearly, indicating where operators should position themselves when using the machine.
The machine has also been completely re-engineered, with parts given simper names to help the workers understand what they are.
A locking interface was introduced for the piston and centre hole, and the bottom half of the machine has windows so workers can ensure that the cavity is empty.
MOM’s officer also added that there are now pressure valve regulators in the machines to allow only the appropriate pressure to be applied.
The metal fence has been redesigned to cover both the front and back of the machine. A professional engineer was engaged to look into the rigidity of the fence and its ability to withstand a certain force.
Feature Image: Adwo / Shutterstock.com
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