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Case studies

The case studies in this section are real incidents with real consequences for those involved. The case studies cover the main causes of injury and occupational ill health in the food and drink industries and include:

Manual handling/Musculoskeletal

Lifting and stacking

Preparing orders in a food warehouse involved bending, pulling and twisting to lift and stack loads weighing up to 50kg onto pallets/roll cages. The warehouse and task was redesigned so that no heavy stock was above shoulder height and the maximum package weight was reduced to 25kg. Injury rates decreased by 30% and costs reduced by 40%. Absenteeism went from 9% to 2% and the cost of implementation was recouped within 12 months.
(taken from Case Study 76 of HSE booklet Moving Food and Drink HSG196)

Awkward movements (lidding)

Baking tin lids were placed and removed from baking tins at a rate of up to 650 per hour by one or two operatives. Staff complaint about the repetitiveness of the work which involved stooping, twisting and holding loads away from the body. The company automated the process at a cost of £16,000. The operators could be redeployed elsewhere, complaints ceased, noise reduced, production improved and the yearly cost saving was between £50-60,000.
(taken from Case Study 28 of HSE booklet Moving Food and Drink HSG196)

Pushing trolleys

Trays of pork cuts were stacked 10 high and pushed on 4-wheel trolleys by production staff. Strains and sprains from pushing the trolleys were common, mainly due to damaged trolley wheels. The company implemented a maintenance programme and employed a person whose main job was to repair, maintain and replace faulty wheels. There was a dramatic decrease in injuries associated with this task, fewer staff complaints and an increase in productivity.
(taken from Case Study 24 of HSE booklet Moving Food and Drink HSG196)

Slips management

Slipping on a wet floor

A worker was injured when walking past a tray cleaning area in a large food factory. The floor was wet from run-off and from prewash spray. The man, who was wearing normal outdoor shoes, slipped and fell, breaking his femur. An improved floor surface with greater microscopic surface roughness was installed to reduce slip risks and control of water spray implemented. Additionally suitable safety footwear was issued with soles that provided better grip in wet conditions.

Slipping in a bakery

In a plant bakery a worker slipped in a puddle of fat on the floor at the corner of a fryer. Her arm went into the reservoir of hot fat in the fryer causing burns to her arm and hand. The fat was leaking from a faulty valve. The valve was replaced and a system set up to spot and clean up spills.

Slipping from the top of plant

An employee was standing on the top of food production plant as she washed it with a hose. She slipped, fell off the plant and fell 2m, breaking her arm. Standing on the plant for cleaning had been condoned within the factory. Safe access arrangements are now provided.


Workers at a company rendering animal products were frequently being injured due to slip accidents. The company carried out a trial using a new shoe with a sole which had been shown to be highly slip resistant when tested wet in DIN ramp tests at HSE's Health and Safety Laboratory. At the end of the seven-month trial, a group of workers using traditional footwear had suffered 15 slip injuries. A similar group using the new footwear had suffered no injuries. The cost of providing the new footwear to the full workforce is around £3,000 set against savings of £10,000 in lost work-time and £6,500 costs for avoided remedial actions.

Falls from height

Fatal fall from stepladder

A cleaner in a meat processing plant died while helping with a deep clean. He used a stepladder on a slippery floor to clean a bowl chopper. He was found lying with head injuries by the bowl chopper with the ladder on top of him. A safe system of work had not been devised or followed.

Fatal fall from lift truck forks

A worker was standing on the raised forks of a fork lift truck (FLT) attempting to locate bulk bags onto the forks. The FLT became overloaded and tilted forward throwing the worker onto the concrete floor from which he received fatal injuries. Standing on the forks of FLTs, or a pallet mounted on the forks, regularly leads to fatal accidents.

Fatal fall from warehouse racking

A cold store operative fell 2m after climbing the racking system in a bulk cold store. He sustained fatal head injuries. This activity was routinely carried out as no safe system of work was provided by the employer.

Further case studies are contained in Food Information Sheet 30 Preventing falls from height in the food and drink industries.

Workplace transport

Vehicle/pedestrian segregation

A new employee was leaving site at the end of the day. He crossed in front of doors used by fork lift trucks and was struck by the forks of a truck as it emerged through the door, breaking his arm as he fell. There was no demarcation of vehicle and pedestrian routes and no marking of doors to indicate their use.

Crushed by reversing vehicle

A worker in a bakery received fatal crush injuries to his head when a shunter (cab) unit was reversing onto a HGV trailer in a loading bay. The workers head became trapped between the reversing trailer and the frame of the loading bay door. Safe systems of work for vehicle reversing operations should be in operation.

Segregation and reversing

A worker was crushed by a reversing FLT against railings which had been provided to separate pedestrians from the vehicle roadway. The FLT driver had reversed without looking and crushed the worker who was on the road side of the railings. The worker should have used the pedestrian route and the driver should have looked before reversing.

FLT overturn

A FLT operator at a coffee manufacturer died when the vehicle overturned and crushed him. The position of the rear wheels suggested the truck may have been turning fairly sharply at the time. Injuries and fatalities from FLTs are disproportionately high and systems need to be in place to ensure their safe use.

Reach truck struck door lintel

An employee at a biscuit manufacturer was driving a reach truck through a doorway when it struck the lintel. The impact caused the lintel to dislodge and this fell on the driver fatally injuring him. Overhead strikes with tall or high reach vehicles occur frequently and need to be considered in risk assessments.

Struck by something

Machine fell on workers

A maintenance fitter was killed and an engineer injured when a large twin arm dough mixing machine fell from the raised forks of a FLT. The machine was on the forks to enable maintenance work from beneath. Many accidents occur during maintenance operations and special attention needs to be paid to ensuring safe systems of work.

Struck by sharp knife

A worker received a serious hand injury when using a sharp hand knife to debone meat. The company now provide knife-proof arm guards and gloves for the non-knife hand and knife-proof aprons.


Crushed in machine

An engineer suffered fatal crushing injuries when working within the danger area of a large robotic palletising machine. The machine started up unexpectedly as it had not been electrically isolated and the power locked off. In food and drink manufacturing, around one fatality a year results from workers entering large machines which have not been safely isolated and locked-off from electric, hydraulic or pneumatic power sources. Systems should be in place to ensure workers entering machines are safe, for example by locking off the power source and the worker taking the key with them into the machine.

Trapped by in-running rollers

A company making naan breads imported a machine for making and flattening the dough. The machine was not CE marked and had unguarded rollers to flatten the dough. A worker feeding flour into the machine slipped on some flour and fell towards the machine putting out a hand to break his fall. His hand was drawn into the unguarded rollers and trapped. He was eventually released by the Fire Brigade and suffered permanent damage to his hand.

Caught in conveyor

A worker cleaning underneath one end of a conveyor belt in a packing area had his hand and arm drawn into the in running nip between the belt and the end roller. His injuries included loss of the arm. Conveyors cause 30% of machinery injuries in food/drink factories and guarding is required which will be effective but allow cleaning (see Food Information Sheet 25 Safeguarding flat belt conveyors in the food and drink industries).

Occupational asthma

Flour dust in craft bakery

A 50-year old female worker who had worked in a small craft bakery all her working life developed what she thought was a wheezy bronchitis. Her work involved making bread and cakes and she was the only baker in the bakery apart from the owner. The women visited her GP who diagnosed occupational asthma and she was unable to continue her employment at the bakery due to her condition.

Flour dust in plant bakery

A 20-year old man was admitted to hospital from work with an acute asthmatic attack caused by flour dust inhalation. In the previous 12 months he had been absent from work for 25 days with chest symptoms. His exposure to flour dust was dramatically reduced by engineering controls and better work methods and he was able to go back to work. In the following three years he did not have any time off with chest problems.


Machine design

In a bakery making fresh frozen buns, metal track conveyors were used to transport metal trays with buns between two machines. The noise level was 94dB(A) and some of this noise was produced by the metal tracking coming into contact with other parts of the machine and the metal trays. The metal tracking on the conveyor was replaced with plastic (polyurethane) tracking at a cost of £600. This reduced the noise level to 87dB(A).
(taken from Case Study 16 of HSE booklet Sound solutions for the food and drink industries)


Glass jars were transported along a conveyor from the jar cleaner to the filler. The glass jars clashed together producing a noise level of 96dB(A). An acoustic enclosure was put over the conveyor at a cost of £2,000 and the conveyor speed was changed to reduce jar clashing. Noise levels were reduced to 86dB(A).
(taken from Case Study 37 of HSE booklet Sound solutions for the food and drink industries)

Occupational dermatitis

Disinfecting tablets

A number of employees in a food production area developed dermatitis. This was traced to water disinfecting tablets which were used to wash vegetables. The employer stopped those who had developed dermatitis working in this area and issued gloves to food handlers subsequently involved in this work. This resolved the problem.


A young female employee handling spices in the development kitchen of a food factory developed dermatitis on her hands, arms, neck and face. The condition improved when she took a week off work but worsened immediately upon her return, necessitating redeployment.

Further case studies are contained in Food Information Sheet 17 Occupational dermatitis in the catering and food industries.

Updated 2017-09-05