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A machinery accident can be analysed effectively by considering not only the immediate unsafe act but also the underlying technical, human, and organisational causes. Consider a case study of a manufacturing plant where a worker suffered a serious hand injury while operating a power-operated mechanical press used for metal sheet fabrication. The press was designed to cut and shape metal components and was equipped with a mechanical guard and a two-hand control system. However, at the time of the accident, the worker was injured when his hand entered the point of operation while attempting to reposition a metal sheet. The accident resulted in severe crushing injuries and temporary loss of working ability. The immediate cause of the accident was the worker's hand coming into contact with the moving ram of the press. The machine cycle was initiated while the worker's hand was inside the danger zone. Initial investigation might suggest that the worker was careless, but a proper safety investigation must go beyond blaming the individual. Accidents generally result from a combination of unsafe conditions and unsafe practices. Therefore, the investigation should examine the machine, work procedures, supervision, training, maintenance practices, and safety management system. One major root cause was inadequate machine guarding. Although the press had originally been fitted with a guard, the guard had been removed during earlier maintenance because it interfered with the positioning of certain components. It was not properly reinstalled before the machine was returned to production. The absence of an effective physical barrier allowed direct access to the point ______ _________ _______ __________ _____ _________ ___ _______.
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