Operations manager, John Stoddart, 42, of Cullompton, Devon, who had worked at the mill since 1988, was reportedly smoothing out felt on a conveyor at Higher Kings Mill when he was pulled into the machinery causing fatal injuries.
The incident was investigated by the HSE and DS Smith Paper, of Euston Road, London, pleaded guilty to a breach of the Provision and Use of Work Equipment Regulations 1998 at Exeter Crown Court this month.
Nigel Hayter, group human resources director, DS Smith, said in a statement: “On September 24, 2011, at DS Smith Paper’s Higher Kings Mill site there was a tragic accident as a result of which John Stoddart, the operations manager at the mill, lost his life.
“Today marks the conclusion of a long and thorough investigation process. We shall always regret the loss of a valued colleague and our commitment to safe operation across our business in 2015 is stronger than ever.”
HSE’s investigation found the company had failed to place any guard around the belt and did not have a suitable risk assessment for work which needed to be carried out to find the cause of creases and for working on the gantry.
The court heard Stoddart was trying to identify a problem that was causing creases in the large rolls of industrial paper being produced.
Fatal crush injuries
Following the practice of some other workers in the factory when similar situations occurred, he climbed onto a work platform to check if the creases were caused by problems on a large, moving felt belt, used to squeeze water out of the pulp mixture.
According to reports, no-one saw what happened to Stoddart, it is likely he was dragged onto the felt belt which then ripped and he fell into the machinery below, causing fatal crush injuries.
He was pronounced dead at Royal Devon and Exeter hospital having been taken there by an ambulance.
“DS Smith’s failure to guard a dangerous piece of moving machinery tragically cost Mr Stoddart his life and has left his family without a husband, father and brother,” said Simon Jones, inspector, HSE after the hearing.
“Potentially dangerous machinery should always be guarded and turned-off when workers need access to repair faults.
“A proper risk assessment would have highlighted these dangers and established safe practices for staff instead of putting their lives at risk.”
Damaged watch found in machinery
At an inquest into the incident in May 2014, Greater Devon Coroner Dr Elizabeth Earland, heard how fellow workers were unsure how Stoddart, who was originally from Sheffield, came to be in contact with and become caught up in the machinery, although his damaged watch was found in the machine afterwards.
At the time, HSE inspector, Jones said he found it “hard to believe” a man could be pulled into machinery by a watch which was not classified as loose fitting like hanging jewellery.
Jason Emery, former engineering manager for the firm said shortly before the incident, a consultancy firm had been engaged to carry out a health and safety assessment at the mill.
The report was allegedly 600 pages long and contained several recommendations but made no specific reference to the piece of machinery Stoddart had been working on prior to his death.
An ambulance was called to the mill at 9.09am and arrived on the scene five minutes later, but Stoddart was declared dead at the Royal Devon and Exeter Hospital later that morning.
Pathologist Dr Roderick Simpson said the victim suffered multiple injuries which included crush wounds to his chest that were consistent with being trapped in rotating machinery.
The inquest heard the cause of death was crushing injury to the chest with contusion of the left lung.