David Ellis, aged 17, reported to New Sun Cookies in Oakville, Ontario, on February 11, 1999 just in time to begin his 7:00 am shift. It was his second day on the job.

The day before, his supervisor, Richard Bates, had spent most of the shift teaching David his responsibilities as a dough mixer operator for the small family-run cookie manufacturer. He was shown how to operate the industrial dough mixer he would be working on, where to find the ingredients, what to add, how long to run the machine and how to remove the dough. The teenager, received no written or formal instructions on how to safely operate the machine, just two verbal tips: 1) Don’t put your hands in the mixer while it’s on, and 2) turn the blades by hand while removing the dough.

David’s father, Rob, said, “He certainly wouldn’t have asked more than “How much am I going to make” and “How many hours am I going to work”.  The supervisor said it would take up to six weeks to train him, but unfortunately, he didn’t follow through with the verbal promise. The Ellis family friend, co-owner Michael Peetz, asked David to come work for him as Michael was experiencing a high turnover.

The mixer had been purchased as a used unit from a bakery supply company three years before. It had no lockout devices and no safety guards. This meant the machine could not be secured against starting when anyone was working near the bladed as is required by law. David was also shown a trick by his supervisors, ‘jogging the blades’ by turning on the mixer for an instant.

In 1992, the Ministry of Labour (MOL) issued an information alert about dough mixer safety. After David Ellis’ accident, the MOL, the Workplace Safety and Insurance Board, (WSIB) and the Industrial Accident Prevention Association (IAPA) all worked together to develop a strategy to prevent dough mixing injuries. This resulted in numerous site visits by inspectors, mailings to companies and a renewed enforcement of safety requirements. Unfortunately, in the same year, three critical injuries were reported: 1) one worker fell into a dough mixer, 2) another’s hand was injured in a mixer, and 3) and one other, again, got him arm caught.

The Ministry of Labour (MOL) decided to make David’s case a top priority for youth safety. New Sun Cookies received three main charges:

1) No machine guards;
2) No energy lockouts; and
3) Inadequate training.

The supervisor went to jail and the company received fines in excess of $60,000.

The sad part, at an interview on W5, the owner stated he realized early on in the investigation that they were in the wrong by not having the protective guards and no safety lockouts. Mind you, he then put his foot in it by stating that he still do not feel they are at fault, it was still just an accident. He didn’t get it. People wonder why stiff fines are used as a deterrent. In this case, stiff fines or not, it was easier to blame a clumsy kid instead of facing the truth.

The truth, David would be alive today if the machine had the proper guards as required under the ACT. David would be alive today if the company followed a Lockout & Tagout policy and procedure as required by the ACT. David would be alive today if the company provided adequate training. The ACT is clear. All three must be part of any work environment and must be in writing.

Section 24 of the ‘Industrial Establishments’ Regulation 851 states,

“Where a machine or prime mover or transmission equipment has an exposed moving part that may endanger the safety of any worker, the machine or prime mover or transmission equipment shall be equipped with and guarded by a guard or other device that prevents access to the moving part.”

Section 42 of the ‘Industrial Establishments’ Regulations 851 states,

“The power supply to electrical installations shall be disconnected, locked out of service and tagged before any work is done, and while it is being done, on or near live exposed parts of the installations, equipment or conductors.”

Section 25 and section 27 of the Act both have the same information,

“The employer and supervisor must take every precaution reasonable in the circumstances for the protection of the worker.”

Section 25 also states,

“The employer shall provide information, instruction and supervision to a worker to protect the health and safety of the worker.”

With all the violations, if this happened today, the fines would have been as much as $25,000 per person per issue and up to a possible 12 moths in jail for each offence and up to $500,000 for the company.

David was a great kid. He cared about his fellow man, did volunteer work, he was deeply religious, and an excellent student. His whole life was there in front of him. He could have been anything he wanted.

New Sun Cookies just got in the way.

HRS Group Inc. has a great team that can help you with all your health and safety needs including Machine Guarding and Lockout and Tagout. Contact Deborah toll free at 1-877-907-7744 or locally at 705-749-1259.

We can also be reached at info@hrsgroup.com

Daniel L. Beal
CHSEP – Foundation Level
VP & Training Director
HRS Group Inc.

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