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Claire is Director of Clarity Safety Solutions Ltd., an Oban-based health and safety consultancy. She has more than 17 years of health and safety experience advising organisations and is a Chartered Member of the Institution of Occupational Safety and Health, an OSHCR registered consultant, and an IFE registered life safety assessor. Since attempting to leave the rat race in 2008, and moving to the West Coast of Scotland, Claire has written hundreds of articles, reports, policies, papers, newsletters, and training courses. Nevertheless, she continues to help clients directly with their health, safety, and fire safety arrangements both within the UK and abroad.
September 9, 2013

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Machinery suppliers 80% liable for £7m factory fire

Two suppliers of factory machinery have been found 80 percent liable for a fire that destroyed about a third of a bakery factory.

In a recent case heard in the Scottish Court of Session, an insurer sought to recoup some of its costs for a GB pound 6,788,566 fire payout. The details of the case contain some useful learning points for those who are assessing fire risk in manufacturing plants.

The fire

The fire broke out at a Bathgate factory owned by United Central Bakeries Ltd (UCB) on 1st November 2006. It started in an area where naan bread was made. The seat of the fire was in a helical conveyor system known as a heliveyor.

The court assessed the fire was probably caused when burning pieces of naan exiting the oven became lodged between plastic modules of the heliveyor belt. The prolonged contact with hot or burning bread would have caused the belt to melt and ignite. Drops of melted materials then landed on lower levels, spreading the fire rapidly.

Click here to view Figure 1.

Why did the belt catch fire?

Essentially, with hindsight, the belt material was not suitable for the application. The belt was made of Polyacetal-POM, a type of thermoplastic commonly used in bakeries. On the face of it, it appeared right for the job.

The problem is that cooking flat breads involves much higher temperatures than other breads. The naan was sprayed with oil and then baked in an oven at 400˚C. Sometimes if the bread stuck to the base of the travelling oven, it would go around twice and then come out of the oven in fragments which would be alight. The maximum tolerance of the belt was around 164˚C, and the manufacturer’s brochure recommended a maximum of 90˚C for product carried.

Knowing all this, it’s evident that burning pieces of bread might cause a fire. Unfortunately, it seems that no single person had all these facts.

Forbo Siegling and Spooner Industries

Despite the mistake, the judge concluded that the machine’s manufacturer, Spooner Industries Ltd., and the belt’s manufacturer, Forbo Siegling (UK) Ltd., were not to blame for the design of the equipment. There was no breach of the Sale of Goods Act 1979, the judge ruled, because POM belting was widely used in bakeries, and the client had not alerted them that burning product regularly found its way on to the conveyor.

However, both of these parties, along with the client, had missed a chance to correct the defect when a fire broke out in 2003. After that fire, both manufacturers sent representatives to the site to try to identify the cause. UCB managers were concerned that the belt material would sustain a flame, whereas similar looking materials nearby on the production line did not.

In subsequent emails, both Siegling and Spooner gave reassurances that the belt was made of suitable materials, and that it was very unlikely that burning naan would set fire to it. Along with the reassurances, they provided a data sheet that had been requested by the client.

Apportionment

The mistake made by the client was not reading the data sheet. One manager said this was because it was “technical” — he perceived it would be too difficult to interpret. As a result of this error of judgment, Lord Hodge found UCB to be 20 percent liable. He said in the ruling:

UCB’s senior managers asked for the data sheet but did not consider it properly when they received it. UCB had the best knowledge of the temperature of ovens. It had the most direct opportunity of testing the temperature of the naan breads exiting oven and of observing the frequency of burning naan breads reaching the heliveyor.

Spooner and Siegling were apportioned more of the blame — 40 percent each.

As the supplier of the heliveyor Spooner was guilty of both negligent misstatement and negligent failure to warn…

Spooner and Siegling should have emphasised the advice about temperatures and flammability in the data sheet and also Siegling’s recommendation in its brochure that the product should not cause the belting to exceed 90˚C. Further, as they were unaware of the temperatures of the customer’s product but were aware of its concerns of the effect of burning naan breads, they should have advised UCB to investigate, or assisted in investigating, the effect of burning naan breads on the POM belting.

In this case, the client should have stuck to its guns. It had been on the right track when it carried out basic tests and expressed its doubts. However, it didn’t follow up on evidence of the belt being scorched in the three years between the two fires. The case teaches us to be wary of opinions on safety-critical matters given by interested parties, and to trust our instincts.

It also underlines the value of ensuring enough time is invested up front in the design of bespoke equipment. Had the designer been more aware of the temperatures and the way in which the process operated, the designer likely would have taken better account of the burning pieces of bread being emitted.

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safeNsane
safeNsane
September 10, 2013 8:09 am

When I read the headline I thought that there had to be either a serious design flaw or that the supplier had something to do with a bad installation and maintenance.  This is somewhat surprising though since it seems like they did things right until they were made aware of potential hazards.  I don’t know how much time the manufacturer spends making bread on their own machines but I’m sure it’s difficult if not impossible to replicate every single situation that their machines could be put though.  Although the manufacturer is being held responsible for alerting the users that they… Read more »

Claire Rizos
Claire Rizos
September 10, 2013 8:27 am
Reply to  safeNsane

You’re right SafeNSane. And there was evidence that the belt got scorched and damage in the 3 years between the two fire incidents. So the bakery should have questioned the validity of the reassurances they’d been given. The mistake the manufacturers made was in being overkeen to persuade the client that the belt was suitable, rather than emphasising the tolerances of it and suggesting further tests. The implication was that they were motivated to protect their position and I guess  they would not want to pay out for a replacement system or have to refund the client the £34k for… Read more »

safeNsane
safeNsane
September 11, 2013 7:21 am
Reply to  Claire Rizos

I can agree that the manufacturer probably should have made a trip out to see the belt and should have stressed the temperature limits but to me this is kind of like buying a sports car then going after the manufacturer when you crash it at high speed.   I’ve seen some crazy things when it comes to products not being used the way they were intended, if every manufacturer got sued when someone was ignoring safety warnings we would have a lot fewer options out there.

gbrown
gbrown
September 11, 2013 11:44 pm
Reply to  safeNsane

l agree and l think the end users and manufacturers must have joint responsibilities and as you mentioned, the bakery company should have spotted the defect of the product in order to prevent its further usage

Rob Ratcliff
Rob Ratcliff
September 12, 2013 6:08 am
Reply to  Claire Rizos

It does seem incredible that that the manufacturers of the equipment ultimately took 80% of the liability between them. I’d have thought that the factory owners were at least 50% culpable in a case like this

safeNsane
safeNsane
September 12, 2013 7:17 am
Reply to  Rob Ratcliff

I think I’d shift that responsibility around to 80/20 heavy on the bakery taking the bulk of the responsibility for the fire.  You can build the safest product in the world but if someone is misusing it then the potential for damage is there.  I’m really surprised that the manufacturers couldn’t find anything in a set of operating instructions that said something like “keep the belt clear of burnt product” or anything close to that.  Giving even an simple set of instructions like that seems like enough to put the responsibility on the bakery to be watching what is on… Read more »

SFX Supervisor
SFX Supervisor
September 12, 2013 9:54 am

Perhaps we should look at the real culprit, the inventor of Naan Bread, surely they to can  be held liable? the fact that they should have realised that, one day, some one would mass produce the product and that in so doing would potentially burn the bread thus causing a fire? why didn’t they incorporate a fire suppressant in the ingredients? and whilst we are at it could we not site the negligence of King Alfred in the case of the burnt cakes? The Gods having looked down and finding us wanting, have decided to destroy us, for truly, we… Read more »

BearFacts
BearFacts
October 21, 2013 11:30 am

This is a complicated case. I suggest that interested people should read the full opinion of Lord Hodge, which, as it is a Scottish case, is available on line. The real issue is whether the designer has been negligent, and whether a statement made by the defendants (to the effect that the POM material cannot be ignited by a flame) should have an effect on the decisions taken. POM was shown to be flammable by the bakery, but was told by the suppliers that the test was invalid. No-one thought to apply a match to the material, unfortunately – as… Read more »

Rob Ratcliff
Rob Ratcliff
October 21, 2013 12:24 pm
Reply to  SFX Supervisor

It’s true, and the nature of our litigous society saddens me, though at least we’re not quite at the same level as the US… yet.
I used to work for a well-known national broadcaster and the risk assessments we used to produce there were IN-CREDIBLE. If you’re ever at home wondering why creative output takes so much time, then look at the risk assessments and you’ll find out what everyone spends their time doing… (well, you’ll know being in the SFK game, of course)

Rob Ratcliff
Rob Ratcliff
October 21, 2013 12:26 pm
Reply to  BearFacts

Thanks, we really struggled to find an image at all of what the equipment might have looked like, that was the closest example we could find. Hopefully the image isn’t misleading, but apologise if so.

Rob Ratcliff
Rob Ratcliff
October 21, 2013 12:31 pm
Reply to  BearFacts

Also, thanks for sharing the link. It’s interesting stuff – this part interests me: “Spooner was the vendor of the heliveyor. Having failed to consider the risk of fire at the time of supply, it sought to create the impression that the POM belt was fit for purpose after the first serious fire. As the supplier of the heliveyor Spooner was guilty of both negligent misstatement and negligent failure to warn.”
Certainly sounds, as you say, a degree of commercial pressures to be behind Spooner’s desire to ‘create the impression’ the belt was fiup to the job.

BearFacts
BearFacts
October 21, 2013 12:37 pm
Reply to  Rob Ratcliff

As to the image – yes – I don’t think Spooner publish one. Basically it is similar to this:
http://www.exapro.com/used-ij-white-ambient-spiral-cooling-conveyor-cold-room-p30327242/
though this is not by Spooner and has a stainless mesh belt.

BearFacts
BearFacts
October 21, 2013 12:49 pm
Reply to  Rob Ratcliff

The email exchange between UCB (the baker) and Spooner are given in an earlier opinion by Lord Hodge, from 2012: http://www.scotcourts.gov.uk/opinions/2012CSOH111.html If your readers study these, you will see the basis on which Lord Hodge made his decision. It was no snap decision on his part! There was a further consideration in this case as to whether the “common duty of care” from the equipment supplier could be governed by statutory (safety) regulations. Your readers may care to comment. The relevant parts of the judgement state (with reference to the expert witness report on negligence): [11] While I have had… Read more »