Steel Coil Falls on Worker — The Gap Between Two Machines That No Guard Covered

Steel Coil Injury — When the Gap Between Two Machines Becomes the Hazard Zone

Let's talk about what happened at Nelson Steel's coil processing facility in Stoney Creek on November 8, 2023. The facility processes steel coils, which travel from a turnstile — a mechanism that rotates the coils — to a down-ender table, which lowers them into a horizontal position for the packaging line. The space between these two machines is where the coil transitions. It is also where workers sometimes need to perform hands-on maintenance. On November 8, 2023, a worker noticed that the tail of a coil had popped out of position. The worker entered the area between the turnstile and the down-ender table to repair it. They leaned over the coil to make the correction. At the control panels nearby, a different worker inadvertently activated the turnstile pusher — the mechanism that moves the coil from the turnstile arm onto the transfer system. With the repairing worker leaning over the coil, the pusher drove the coil off the turnstile arm. The coil fell to the ground and injured the worker who had entered the space to perform the repair. There was no guard or shield between the two machines that would have prevented the worker from entering the hazard zone, or that would have triggered an automatic stop if a worker was in the area. Following the incident, the company complied with a Ministry order to shield or guard the incident area. That after-the-fact compliance is telling: the guard was achievable before the injury occurred. It just wasn't in place. Samuel, Son & Co. pleaded guilty in the Ontario Court of Justice in Hamilton and was fined $125,000 plus a 25% victim fine surcharge.

What the Law Requires

Section 26 of Ontario Regulation 851 requires that where a worker works in proximity to any exposed moving part of a machine that may endanger their safety, the part shall be protected by a guard or other device that will prevent access to the exposed moving part. Basically, what this means is simple: if workers can enter the space between two connected machines, and that space contains hazards from moving equipment or material, that space must be guarded or shielded. It is not sufficient to rely on the worker's awareness of the hazard or on other workers not making inadvertent control errors. Accidental activation of adjacent machine controls is a foreseeable event in any multi-machine production environment. When a worker is performing a repair in the transfer zone between two machines, the risk that another worker at the controls might activate something is real and must be controlled. A guard or interlock that prevents worker access while the machine can be activated — or that stops machine movement when a worker is in the zone — is the type of control Section 26 of O. Reg. 851 is designed to require. The company's post-incident compliance with the Ministry order to shield the area confirms that the guard was not a novel engineering challenge. It was simply not installed before the injury. In the court's view, this was a fundamental failure to guard a known hazard area in a production line — not a failure to anticipate something unusual. The $125,000 fine reflects the directness of the violation and the severity of the injury.

What Supervisors Must Do

• Identify all transfer and transition zones between machines in your production lines where workers may need to enter during repairs or maintenance, and confirm that these zones are guarded or shielded
• Implement a lockout/tagout procedure for any in-zone repair work: before a worker enters the space between two machines, controls that can move material into or through that zone must be locked out
• Establish and enforce a no-entry-without-lockout rule for the transfer zones between the turnstile, down-ender, and any other connected machine components
• Communicate clearly to all workers at control panels: if a coworker is in a machine transition zone, no controls that affect that zone may be activated until the worker is confirmed clear and lockout is removed
• Keep asking: 'If a worker entered that zone right now to fix something, what stops another worker at the controls from inadvertently activating a movement sequence that reaches into that zone?'

What Employers Must Do

• Conduct a guarding audit of all production line machine interfaces — specifically the transition zones between connected machines where material handoff occurs; confirm that each zone is guarded or shielded against worker access during operations
• Implement interlocks or physical shields at all machine transition zones that prevent worker entry when machine sequences are active
• Develop machine-specific lockout/tagout procedures for every in-production-line repair task, including tail-coil repairs between turnstile and down-ender; these procedures must be written, trained, and signed off before workers perform the task
• Review your incident and near-miss records for inadvertent control activations; if other workers have accidentally activated controls before, that pattern is direct evidence of a control system gap
• Post-incident compliance with Ministry orders is evidence of what was achievable before the incident — do not wait for an order to install guards that are plainly needed in your production line
• Include all machine transition zones in your annual guarding audit and O. Reg. 851 compliance review

How to Use This Case in Your Workplace

This case is a valuable safety conversation starter. Use it during toolbox talks for all workers involved in in-line maintenance and repair tasks on packaging and processing lines, monthly safety meetings for industrial supervisors, and machine guarding audits in steel processing or any multi-machine production environment. Walk your team through the production floor and ask: 'Is there any space between two connected machines in this facility where a worker might enter to perform a repair — and is that space guarded or locked out before anyone enters it?' 'If someone inadvertently activated a control while a coworker was in a machine transition zone right now, what physical control would prevent an injury?' 'When was the last time we verified that lockout procedures for in-line repair tasks are being followed on every shift?' This case reinforces a simple message: the gap between two connected machines on a production line is a hazard zone — and the employer's obligation to guard it does not disappear because the injury requires two simultaneous events to occur.