The worker was changing dies on a punch press machine. It was a routine task — the kind of work that happens dozens of times a day in industrial facilities across Ontario. At some point during the die change, the worker reached through an unguarded gap to clean debris near the punch press blades.
A second worker, who did not see the first worker's hand inside the machine, activated the press.
The result was a critical injury — the kind that changes a person's life permanently.
What Happened
On July 21, 2023, a worker employed through a temporary help agency was performing a die change on a punch press at Grosnor Industries Inc.'s facility at 375 Rexdale Blvd. in Etobicoke. Grosnor produces textile samples for clients in the roofing, flooring, tile and siding industries.
During the die change, the worker reached through an unguarded gap in the machine to clean debris near the punch press blades. The exposed moving part created a shearing hazard — a danger zone that could crush, cut, or amputate anything that entered it while the machine was in operation.
A second worker was nearby. That worker did not see the first worker's hand in the machine. They activated the punch press. The first worker sustained a critical injury.
A Ministry of Labour investigation confirmed what should have been obvious before the incident: the exposed moving part generating the shearing hazard was not equipped with a guard or other device to prevent worker access. There was no barrier. There was nothing to stop a hand from going where it shouldn't.
Grosnor Industries Inc. pleaded guilty in the Ontario Provincial Offences Court in Toronto and was fined $50,000 plus a 25% victim fine surcharge.
What the Law Says
Section 24 of Ontario Regulation 851 (Industrial Establishments): "Where a machine part, function or process may endanger a worker, the machine part, function or process shall be guarded or enclosed by a guard or other device that prevents access to the moving part from any direction."
Basically, what this means is simple: if a part of a machine is moving and can hurt someone, it must be guarded. Not sometime. Not when it's convenient. All the time it is in operation.
The fact that the worker was reaching into the machine to clean debris — not during an authorized repair with lockout in place — points to a second failure: there was no procedure that prevented access to the danger zone during die changes. The guard would have made that access impossible. Without it, access was uncontrolled and the injury was predictable.
In the court's view, this was not a freak accident — it was a foreseeable outcome of operating a machine with an unguarded shearing hazard. The conviction and $50,000 fine reflect how seriously the court takes this failure.
Practical Actions for Supervisors
Supervisors control who does what and how on the floor. Here's what the court expects you to do:
Keep asking: "Before this worker reaches anywhere near this machine, is the danger zone physically guarded — and if it's not, is the machine locked out?"
- Before any die change, cleaning, or adjustment task begins near a punch press, confirm the machine is either properly guarded at the point of operation or fully locked out
- Walk the floor and identify every punch press, press brake, or stamping machine where workers routinely reach near the operating zone — these machines must have point-of-operation guards reviewed immediately
- Never allow cleaning of debris near a punch press blade area while the machine is in an operable state without lockout confirmation
- Ensure all workers who perform die changes or press maintenance understand they are never to place any part of their body inside the danger zone unless the machine is locked out — and that the machine must be locked out before any contact
- If a second worker is near a press and could inadvertently activate it, implement a clear communication and authorization protocol before any work begins near the operating zone
Practical Actions for Employers
Employers must build the system that ensures machine guarding is in place at every point of operation. That system must include:
- A full machine guarding audit of every punch press, press brake, and stamping machine at your facility — inventory every exposed moving part, assess whether a guard or device is in place, and address every gap before the next shift
- Written procedures for every die change, cleaning, and adjustment task on press equipment that specify the required controls before any work begins — lockout where the guard is removed, machine-specific guard verification before restart
- Training for all operators and maintenance workers on the specific guarding requirements for each press they use — and clear instruction that reaching into an unguarded danger zone is prohibited under any circumstances
- A guard removal permit system: if a guard must be removed for maintenance, it must be documented, authorized, and reinstated before the machine returns to operation
- Regular supervisory inspections of all press guarding — at the start of each shift, supervisors must confirm that all guards are in place before production begins
- Corrective action protocols: any missing or damaged guard must result in the machine being taken out of service until the guard is reinstated — not tagged for future repair while the machine continues to run
Employers must demonstrate due diligence, meaning documented, proactive efforts to prevent machine guarding failures. This case shows that "the worker shouldn't have reached in there" is not a defense — the rule is clear, and the guard is what enforces it.
How to Use This Case in Your Workplace
This case is a valuable safety conversation starter. Use it during:
- Pre-shift toolbox talks on any floor with punch presses, press brakes, or stamping equipment
- Machine guarding audits — walk your machines with this case in hand
- Training sessions for new workers on the prohibition against reaching near operating press equipment
Walk your team through the floor after reviewing this case. Ask:
- "For every punch press on this floor, can a worker's hand reach the blade area while the machine is in an operable state?"
- "What is the procedure when a worker needs to clean debris from near the press blades?"
- "Is the guard on this machine in the same condition as the last shift — or has something changed?"
This case reinforces a simple message: a punch press with an unguarded shearing hazard is a machine waiting to injure the next worker who gets close enough.
Case Summary
- Hazard Type: Machine Guarding · Point-of-Operation Guard · Punch Press
- Root Cause: Exposed moving part (shearing hazard) on punch press not equipped with a guard or access-preventing device
- Immediate Cause: Worker reached into unguarded danger zone during die change; second worker activated the machine
- System Gaps Identified:
- No point-of-operation guard on the punch press
- No access-preventing device on the shearing hazard zone
- No effective procedure controlling worker access during die changes and debris cleaning
- Temporary help agency worker placed in a hazardous task without adequate machine-specific protection
- Key Teaching Point: Section 24, O. Reg. 851 requires that every exposed moving part that can endanger a worker be guarded by a device that prevents access. Ordering a guard after an injury is not compliance — it confirms the guard was achievable before the injury occurred.
- Conviction Details:
- Who: Grosnor Industries Inc., 375 Rexdale Blvd., Etobicoke, Ontario
- When: Offence July 21, 2023; Conviction February 27, 2026
- Where: 375 Rexdale Blvd., Etobicoke, Ontario
- Penalty: $50,000 fine + 25% victim fine surcharge
- Court: Ontario Provincial Offences Court, Toronto; Justice of the Peace Pete Karageorgos