[Death in the Bread Factory] ③Common Factors Behind Fatalities Involving Dangerous Machinery

Negligence in Management Despite Established Safety Systems

Editor's NoteWill simply eliminating nighttime overtime and reducing work intensity, as ordered by President Lee Jaemyung, solve everything? The core issue behind the recurring fatal entrapment accidents at SPC Group factories is that workers operating unmanaged machines could not stop the equipment when they sensed danger. Asia Economy has reconstructed the sequence of three fatal accidents and the machines involved, examining the moments when these tragedies could have been prevented.

SPC Group sources most of its bread-making machines through custom orders. After a review of investment in machine facilities, a bidding process for procurement follows. Once the machines to be installed on the production line are selected, the production center (factory) and the safety department conduct safety inspections alongside installation. There is also a separate inspection system to check whether emergency stop buttons are installed at all workstations and whether safety devices are functioning properly. This demonstrates that SPC Group is fully aware of the risks associated with factory machinery.

On the 27th, a truck is leaving the SPC Samlip factory in Siheung, Gyeonggi Province. Photo by Kang Jinhyung

However, three workers have died in machinery entrapment accidents at the factories. This means that although a system was in place, it did not function as intended. Circumstances such as ①intervening during machine operation, ②absence or malfunction of safety devices, and ③emergency stop buttons out of reach indicate that these were not simply accidents, but human-caused incidents resulting from lax management that failed to enforce proper procedures.

Asia Economy has produced 3D graphics to illustrate the dangers of the machines involved in these accidents. Please be advised that some of the graphics and descriptions used to reconstruct the events may depict distressing scenes.

①Forcing the Body into Moving Machinery

On May 19th at 3 a.m. this year, a 3D reconstruction was made of the operation of the "Spiral Cooling Conveyor" at the SPC Samlip factory in Siheung, Gyeonggi Province, where the accident occurred. Mr. Yang entered the lower part of the running machine to spray lubricant. There was no emergency stop button at the lower part of the machine.

The victims of SPC's fatal machinery entrapment accidents were working while forcing their bodies into moving machines. On May 19 of this year, Ms. Yang (55, female), who was working at the SPC Samlip factory in Siheung, entered the lower part of a "spiral cooling conveyor" to spray lubricant and was fatally trapped by her upper body. The direct cause of the accident was her entering the operating spiral cooling conveyor to perform the task. (Reference article: SPC Accident Log...Records of Three Victims) According to the Korea Occupational Safety and Health Agency's "Technical Guidelines on Conveyor Safety," conveyor operation must be stopped during maintenance tasks such as cleaning or lubrication.

However, Ms. Yang and other SPC Samlip factory workers frequently entered the lower part of the conveyor to work while the machine was still running. Boxes placed around the spiral cooling conveyor and acrylic panels attached to its lower section were cited as evidence by SPC employees.

Mr. A (56, male), an employee at the SPL factory in Pyeongtaek, which uses the same type of machine on its production line, said, "When the spiral cooling conveyor gets old, it shakes and bread falls down." He added, "Normally, boxes are not needed on the production line, but I believe they were placed around the machine to collect fallen bread." Regarding the acrylic panels, he explained, "They were probably used to mark the usual paths for entering and exiting the machine and to control access as best as possible."

Similarly, Ms. Ko (55, female), who died after being caught in a dough lift at the Shany factory in Seongnam on August 8, 2023, and her colleagues, worked around operating machinery without any intervention. According to Article 92 of the Occupational Safety and Health Standards Regulations, employers must stop the operation of transport machinery (including dough lifts) during maintenance, cleaning, replacement, or adjustment if there is a risk to workers. Despite this, two workers handling the accident machine continued to operate it while replacing the lift nozzle to adjust the dough portion size.

Shany was aware of the risks associated with the dough lift. According to the safety operation manual provided by Shany to Justice Party leader Kwon Youngguk at the time, the company identified the risk of entrapment during lift ascent and descent, as well as the danger of mixing bowls falling, as hazards for the accident machine.

On October 15, 2022, Ms. Park (23, female) died at the SPL factory in Pyeongtaek after reaching into an operating "sauce mixer" to loosen clumped sauce. This violated the Korea Occupational Safety and Health Agency's "Technical Guidelines on Safe Operation of Food Processing Machinery," which require machines to be stopped when workers' hands approach hazardous areas, such as when removing processed food. These guidelines were announced in November 2012, ten years before the accident.

②No Safety Devices to Prevent Emergencies

The accident that occurred on August 8, 2023, at 12:33 PM at the dough lift of the Shani factory in Seongnam, Gyeonggi Province was recreated in 3D. Workers were able to approach the machine despite being in the middle of tasks such as adjusting the dough quantity. No warning sound was emitted, making the accident unavoidable.

Even if workers inevitably violated regulations and approached operating machinery, there were no devices on site to prevent or alert them to dangerous situations. The dough lift is designed to emit a warning sound when descending, alerting workers to danger. However, the warning sound on the dough lift at the Shany Seongnam factory did not function properly. This is why Ms. Ko was completely unaware that the mixing bowl was descending and became trapped. On August 16, 2023, members of the 21st National Assembly's Environment and Labor Committee visited the Shany Seongnam factory to investigate the cause of the accident. At the time, Assemblyman Park Jung of the Democratic Party of Korea, who visited the site, said, "It is said that the alarm did not sound on the machine involved in the accident; it should be further investigated whether someone turned it off manually."

The sauce mixer should also have a lid on the mixing container to prevent hands from being inserted. If the lid must be opened, an interlock device that automatically stops the machine is mandatory. An interlock is a device that automatically stops the machine under certain conditions, such as when the lid is opened. However, the sauce mixer Ms. Park was working on did not have an interlock. According to the first trial verdict from the Suwon District Court Pyeongtaek Branch, which sentenced former SPL CEO Kang Dongseok to one year in prison with a two-year suspended sentence in January for violating the Serious Accidents Punishment Act, SPL had recognized the risk of accidents and reviewed the installation of an interlock on the sauce mixer during its own weekly inspections before the incident occurred. Article 93 of the Occupational Safety and Health Standards Regulations states that employers must not dismantle or deactivate safety devices.

SPC Samlip Sihwa Factory, Siheung, Gyeonggi Province. Photo by Kang Jinhyung

In the case of the spiral cooling conveyor, installing a fence with an "interlock" could have prevented the accident. There are also other types of braking devices besides fences. Mr. A said, "At SPL, there is an interlock around the spiral cooling conveyor. If you pull the cord in an emergency, the machine stops." However, according to the Siheung Fire Department, only acrylic panels, not a fence with an interlock, were installed around the spiral cooling conveyor at the SPC Samlip factory in Siheung.

Seo Yongyun, professor of Industrial Systems Engineering at Dongguk University, said, "The absence of a fence is a clear violation of the Occupational Safety and Health Act. It is also standard practice to install safety devices between the conveyor belts to prevent fingers from getting caught, but this was not followed."

③Emergency Stop Buttons Out of Reach

Factory workers must be able to press the emergency stop button in dangerous situations during their shifts. Article 88 of the Occupational Safety and Health Standards Regulations stipulates that employers must install machine power cut-off devices within reach of the worker's position, so they can operate them without moving.

The accident that occurred on October 14, 2022, at the sauce mixer in the SPL factory in Pyeongtaek, Gyeonggi Province, was recreated in 3D. The emergency stop button was located on the right control panel but was out of reach without moving closer.

Ms. Park, who died of asphyxiation in the sauce mixer, had her right arm caught in the rotating blade, pulling her upper body into the mixing container. Ms. Park's height was 160 cm, and the average arm length for a woman of that height is about 55 cm. However, the distance from the far right end of the mixing container to the emergency stop button was 108 cm, making it practically impossible to press the button without moving.

The same was true for Ms. Ko. The emergency stop button for the dough lift was clustered with the up and down buttons on the control panel attached to the left pillar of the mixing bowl. During the nozzle replacement on the dough lift, workers had to stand behind the pillar, so the control panel was out of sight. At the time of the accident, Ms. Ko was raising her arm to replace the nozzle, with her upper body and head facing the right side, away from the emergency stop button. It is presumed that it would have been even more difficult for her to press the emergency stop button, which was out of her line of sight.

'Legal Review on the Death Accident of SPC Shany Seongnam Factory Worker Caught in Machinery' written by Kwon Youngguk, leader of the Justice Party and former standing representative of the 'Paris Baguette Workers Cheer-up Joint Action.' In August 2023, Ms. Ko (55, female) was caught in a dough lift and died at the Shany Seongnam Factory. Photo by Kang Jinhyung

The spiral cooling conveyor, where the most recent fatal accident occurred, was designed so that no one would need to enter its lower section; thus, there was no emergency stop button installed there. If there had been a procedure requiring workers to enter the lower part, an emergency stop button should also have been installed in that area. The emergency stop button, which could halt the machine, was located on a control panel out of reach from the lower section of the conveyor belt.

For more details on SPC's machinery entrapment accidents, visit Asia Economy's Visual News. https://www.asiae.co.kr/en/visual-news/article/2025091015165318961