Coroner's Finding: Knight, Daniel Thomas
Deceased
Daniel Thomas Knight
Demographics
43y, male
Date of death
2014-11-12
Finding date
2024-03-26
Cause of death
Crush injuries (chest and abdominal injuries and chest compression) sustained in a wastepaper compactor accident
AI-generated summary
Daniel Thomas Knight, aged 43, died from crush injuries sustained while attempting to clear a blockage in a wastepaper compactor (model TCU 660) at a printing business. The compactor had never functioned correctly due to missing safety components (rotary valve, airlock, or air balancing fan), requiring frequent unblocking. Despite being told not to touch the machine and despite the air and power being switched off, both were mysteriously switched back on. Mr Knight entered the compactor with a rake to clear a blockage and accidentally contacted the left-hand compacting ram, which retracted and then extended, trapping him between both rams under 5 kilonewton force. Multiple safety failures contributed: inadequate machinery design and installation, no staff training on isolation procedures, failure to dissipate stored energy, and lack of proper guarding and interlocks. Prompt recognition and CPR attempted, but injuries were fatal.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Compactor not functioning correctly due to missing rotary valve or airlock
- Frequent jamming requiring manual unblocking
- Air supply and electrical power switched back on despite being turned off
- No energy isolation procedure in place
- No proper guarding or interlocks to prevent ram movement when guard opened
- No training or instruction provided to Mr Knight on machinery isolation
- Stored pneumatic energy not dissipated when front guard opened
- Right-hand ram leaking causing overnight creep
- Vinyl strip covering control panel preventing visibility of power status
- Lack of site-specific risk assessment by machinery manufacturer
- Inadequate design of electrical and pneumatic control systems
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