Safety distance assessment form

Logo of the project TeSaMa		Form symbol XXX		Machine ID XXX-XXX				Form date (date when assessment of safety measures addressing mechanical hazards started) xxxx-xx-xx
Machine name, type and location			Hazard zone
Safety distance assessment (according to PN-EN ISO 13855:2010 and PN-EN ISO 13857:2010)
Item	Requirement				Requirement fulfilment		Notes:
					Yes or Not applicable	No
Positioning of protective equipment with respect to the approach speeds of the human body parts
1.	Determination of the safety distance for the electro-sensitive protective equipment (AOPD) – approach direction perpendicular to the detection plane – location of the detection zone is vertical – detection of the whole body – detection threshold d ≤ 40 mm Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K₁ = 2,000 mm/s Approach speed K₂ = 1,600 mm/s Detection threshold d = ………………. Additional distance C = 8 (d – 14) = …………………. Distance S₁ = (K₁ x (t₁ + t₂)) + C = ………………….. Distance S₂ = (K₂ x (t₁ + t₂)) + C = ………………….. Safety distance S = (if S₁ < 500 mm, then S = S₁) or (if S₁ ≥ 500 mm, then S = max (S₂, 500 mm)) = …………………………….
2.	Determination of the safety distance for the electro-sensitive protective equipment (AOPD) – approach direction perpendicular to the detection plane – location of the detection zone is vertical (also the location of the detection zone at an angle of > 30°) – detection threshold d ≤ 30 mm – protective equipment is used for reinitiation of the working cycle of the machine Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K = 2,000 mm/s Detection threshold d = ………………. Additional distance C = 8 (d – 14) = …………………. Safety distance S = max (((K x (t₁ + t₂)) + C), 150 mm) = …………………..
3.	Determination of the safety distance for the electro-sensitive protective equipment (AOPD) – approach direction perpendicular to the detection plane – location of the detection zone is vertical (also the location of the detection zone at an angle of > 30°) – detection threshold d ≤ 14 mm Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K = 2,000 mm/s Detection threshold d = ………………. Additional distance C = 8 (d – 14) = …………………. Safety distance S = max (((K x (t₁ + t₂)) + C), 100 mm) = …………………..
4.	Determination of the safety distance for the electro-sensitive protective equipment (AOPD) – approach direction perpendicular to the detection plane – location of the detection zone is vertical (also the location of the detection zone at an angle of > 30°) – detection threshold 40 mm < d ≤ 70 mm – risk assessment indicates no need to detect hands Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K = 1,600 mm/s Additional distance C = 850 mm Safety distance S = K x (t₁ + t₂) + C = …………………..
5.	Determination of the safety distance for several (2, 3, 4) separate light beams – approach direction perpendicular to the detection plane – location of the detection zone is vertical (also the location of the detection zone at an angle of > 30°) Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K = 1,600 mm/s Additional distance C = 850 mm Safety distance S = K x (t₁ + t₂) + C = …………………..
6.	Determination of the safety distance for a single light beam – approach direction perpendicular to the detection plane – location of the detection zone is vertical (also the location of the detection zone at an angle of > 30°) Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K = 1,600 mm/s Additional distance C = 1,200 mm Safety distance S = K x (t₁ + t₂) + C = …………………..
7.	Determination of the safety distance for the electro-sensitive protective equipment (AOPD) – approach direction parallel to the detection plane – location of the detection zone is horizontal (also the location of the detection zone at an angle of ≤ 30°) Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Detection threshold d = ………………. Approach speed K = 1,600 mm/s Minimum location height of the detection plane H_min + max ((15 (d – 50)),0) = ……………. Location height of the detection plane H = ………………….. Additional distance C = max ((1,200 mm – 0.4 x H), 850 mm) Safety distance S = K x (t₁ + t₂) + C = …………………..
8.	Determination of the safety distance with the possibility to bypass (reach) the electro-sensitive protective equipment above the detection zone – approach direction perpendicular to the detection plane – location of the detection zone is vertical Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K₁ = 2,000 mm/s Approach speed K₂ = 1,600 mm/s Hazard zone height a = ……………………. Height of the upper edge of the detection zone for the electro-sensitive protective equipment b = ………………………. Additional distance (based on table 1 of PN-EN ISO 13855:2010) C_RO = …………………. Distance S₁ = (K₁ x (t₁ + t₂)) + C_RO= ………………….. Distance S₂ = (K₂ x (t₁ + t₂)) + C_RO= ………………….. Safety distance S = (if S₁ < 500 mm, then S = S₁) or (if S₁ ≥ 500 mm, then S = max (S₂, 500 mm)) = …………………………….
9.	Determination of safety distance for a pressure-sensitive mat/floor with a possibility of mounting the mat/floor on an elevation (step) Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K = 1,600 mm/s Step height h = ………………. Safety distance S = K x (t₁ + t₂)+ 1,200 – 0.4 h = …………………..
10.	Determination of safety distance for a two-hand control device Machine after-running time t₁ = ………………… Approach speed K = 1,600 mm/s Safety distance S = K x t₁+ 250 = …………………..
11.	Determination of safety distance for a single-handed operation maintenance device Machine after-running time t₁ = ………………… Approach speed K = 1,600 mm/s Safety distance S = K x t₁+ 1,700 = …………………..
12.	Determination of safety distance for locking guard without a locking device – persons aged 14 years and above Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K = 1,600 mm/s Reaching by part of the body (fingertip, finger to base, palm, upper limb to the shoulder joint): Dimensions (diameter) of the hole e = ………………………….. Minimum safety distance (based on table 4 of PN-EN ISO 13857:2010) C = …………………. Safety distance S = K x (t₁ + t₂) + C = …………………..
13.	Determination of safety distance for locking guard without a locking device – persons aged 3 years and above Machine after-running time t₁ = ………………… Protective equipment activation time t₂ = ……………….. Approach speed K = 1,600 mm/s Reaching by part of the body (fingertip, finger to base, palm, upper limb to the shoulder joint): Dimensions (diameter) of the hole e = ………………………….. Minimum safety distance (based on table 5 of PN-EN ISO 13857:2010) C = …………………. Safety distance S = K x (t₁ + t₂) + C = …………………..
14.	Determination of safety distance for locking guard without a locking device – persons aged 14 years and above – electrically-driven opening of the guard Machine after-running time t₁ = ………………… Opening width of the electrically-driven guard e = ………………….. Opening speed of the electrically-driven guard v = ………………….. Opening time of the guard t₃ = e/v = ………………. Approach speed K = 1,600 mm/s Reaching by part of the body (fingertip, finger to base, palm, upper limb to the shoulder joint): Dimensions (diameter) of the hole e = ………………………….. Minimum safety distance (based on table 4 of PN-EN ISO 13857:2010) C = …………………. Safety distance S = K x (t₁ + t₃) + C = …………………..
15.	Determination of safety distance for locking guard without a locking device – persons aged 3 years and above – electrically-driven opening of the guard Machine after-running time t₁ = ………………… Opening width of the electrically-driven guard e = ………………….. Opening speed of the electrically-driven guard v = ………………….. Opening time of the guard t₃ = e/v = ………………. Approach speed K = 1,600 mm/s Reaching by part of the body (fingertip, finger to base, palm, upper limb to the shoulder joint): Dimensions (diameter) of the hole e = ………………………….. Minimum safety distance (based on table 5 of PN-EN ISO 13857:2010) C = …………………. Safety distance S = K x (t₁ + t₃) + C = …………………..
Safety distances to prevent hazard zones being reached by upper and lower limbs
16.	Determination of safety distance when reaching upwards – low risk Safety distance h > 2,500 mm
17.	Determination of safety distance when reaching upwards – high risk Safety distance h > 2,700 mm
18.	Determination of safety distance when reaching by upper limbs above the protective structures – low risk Danger zone height a = ……………………. Horizontal distance from danger zone c = ……………………………… Minimum height of the protective structure (based on table 1 of PN-EN ISO 13857:2010) b = ………………….
19.	Determination of safety distance when reaching by upper limbs above the protective structures – high risk Danger zone height a = ……………………. Horizontal distance from danger zone c = ……………………………… Minimum height of the protective structure (based on table 2 of PN-EN ISO 13857:2010) b = ………………….
20.	Determination of safety distance when reaching around by upper limb Dimensions (diameter) of the hole a = ………………………….. Dimensions of an obstacle limiting movement l = ……………………. Safety distance (based on table 3 of PN-EN ISO 13857:2010) s_r = …………………………..
21.	Determination of safety distance when reaching by upper limbs through holes of regular shape – persons aged 14 years or above Reaching by part of the body (fingertip, finger to base, palm, upper limb to the shoulder joint): Dimensions (diameter) of the hole e = ………………………….. Safety distance (based on table 4 of PN-EN ISO 13857:2010) s_r = …………………………..
22.	Determination of safety distance when reaching by upper limbs through holes of regular shape – persons aged 3 years or above Reaching by part of the body (fingertip, finger to base, palm, upper limb to the shoulder joint): Dimensions (diameter) of the hole e = ………………………….. Safety distance (based on table 5 of PN-EN ISO 13857:2010) s_r = …………………………..
23.	Determination of safety distance when reaching by upper limbs through holes of irregular shape – persons aged 14 years or above Reaching by part of the body (fingertip, finger to base, palm, upper limb to the shoulder joint): Diameter of the smallest round hole e₁ = ………………………….. Dimensions of the smallest square hole e₂ = ………………………….. Dimensions of the smallest slot hole e₃ = ………………………….. Minimum safety distance for the round hole dimensions (based on table 4 of PN-EN ISO 13857:2010) s_r1 = ………………………….. Minimum safety distance for the square hole dimensions (based on table 4 of PN-EN ISO 13857:2010) s_r2 = ………………………….. Minimum safety distance for the slot hole dimensions (based on table 4 of PN-EN ISO 13857:2010) s_r3 = ………………………….. Safety distance for a hole of irregular shape s_r = min (s_r1, s_r2, s_r3) = ……………….
24.	Determination of safety distance when reaching by upper limbs through holes of irregular shape – persons aged 3 years or above Reaching by part of the body (fingertip, finger to base, palm, upper limb to the shoulder joint): Diameter of the smallest round hole e₁ = ………………………….. Dimensions of the smallest square hole e₂ = ………………………….. Dimensions of the smallest slot hole e₃ = ………………………….. Minimum safety distance for the round hole dimensions (based on table 5 of PN-EN ISO 13857:2010) s_r1 = ………………………….. Minimum safety distance for the square hole dimensions (based on table 5 of PN-EN ISO 13857:2010) s_r2 = ………………………….. Minimum safety distance for the slot hole dimensions (based on table 5 of PN-EN ISO 13857:2010) s_r3 = ………………………….. Safety distance for a hole of irregular shape s_r = min (s_r1, s_r2, s_r3) = ……………….
25.	Determination of safety distance when reaching by upper limbs through holes with additional protective structures Type of movement limitation: ………………………………….. Safety distance (based on table 6 of PN-EN ISO 13857:2010) s_r = …………………………..
26.	Determination of safety distance when reaching by lower limbs through holes of regular shape Part of a lower limb (toe tips, toes, foot, leg up to a knee, leg up to a crotch): Type of hole (slot, square or circle): ……………………… Dimensions of the hole e = ………………………….. Safety distance (based on table 7 of PN-EN ISO 13857:2010) s_r = …………………………..

Persons determining safety distances							Date
Summary of the safety distances determination process

Assessment form for the measures preventing accidental start-up

Logo of the project TeSaMa		Form symbol XXX		Machine ID XXX-XXX				Form date (date when assessment of safety measures addressing mechanical hazards started) xxxx-xx-xx
Machine name, type and location			Installed measures preventing accidental start-up
Assessment of the measures preventing accidental start-up (according to PN-EN 1037+A1:2010)
Item	Requirement				Requirement fulfilment		Notes:
					Yes or Not applicable	No
1.	Machine is equipped with the device for energy disconnection and dissipation
2.	Machine is equipped with other measures preventing unintended start-up, including signalling and warning devices
3.	Device for isolating from energy sources ensures reliable disconnection
4.	Device for isolating from energy sources ensures reliable mechanical connection between the control element and disconnecting elements
5.	In the device for isolating from energy sources a clear and unambiguous identification of its status corresponding to any location of the control element is ensured
6.	Each device for isolating enables the determination which machine or its part is disconnected
7.	If during the disconnection of the machine some of the circuits have to remain connected to power supply, then additional safety measures for the operator have been applied
8.	Isolating device enables its key-locking or securing in other manner, in the disconnection position
9.	If accumulated energy may cause the increase of risk, then devices for dissipation of accumulated energy have been applied in the machine
10.	If the dissipation of accumulated energy excessively limits the operational readiness of the machine, then it is additionally equipped with the devices for reliable containment or absorption of accumulated energy
11.	Devices for dissipating or containing the energy were chosen and installed so that the dissipation or containment of energy was the effect of the disconnection of machine or its part from power supply
12.	Devices for dissipating or containing the energy were chosen and installed so that the process of energy dissipation does not cause the occurrence of hazard
13.	Necessary energy dissipation or containment procedures are described in user manual or are provided in the form of warnings on the machine itself
14.	If mechanical elements cause the hazard as a result of restoring forces load or by its weight, the possibility of their bringing down to the lowest energetic status with the use of simple control devices, or devices specifically intended and identified for this function, was ensured
15.	Mechanical elements that may not be brought to the intrinsically safe status are mechanically protected by brakes or mechanical devices preventing movement
16.	Containing devices, if necessary, are closed or protected in other manner in the containment position
17.	Machine and devices for disconnection and dissipation of energy are designed, suited and arranged in a manner enabling reliable check-up of the effectiveness of energy disconnection and dissipation
18.	Measures for checking the effectiveness of disconnection and dissipation of energy do not decrease the effectiveness of disconnection or dissipation
19.	Disconnection from any power supply is either visible or indicated by unambiguous setting of the control element in the disconnecting device
20.	For checking of the full discharge of energy in machine components at or in which the interference was expected, measuring devices or connections have been embedded
21.	There are exact guidelines concerning the procedures of safe checking in the machine manual
22.	On the assemblies that may be removed or demounted and which produce a hazard in the form of accumulated energy, fixed plates warning against hazards caused by accumulated energy have been mounted
23.	In cases when disconnection or dissipation of energy is not used with respect to all the methods of interference, the measures preventing the initiation of start signals in any part of the machine as a result of external or internal impacts have been applied
24.	In cases when disconnection or dissipation of energy is not used with respect to all the methods of interference, the measures intended for preventing the accidental initiation of start signals causing unintended start-up have been applied, depending on the configuration/structure of the system
25.	In cases when disconnection or dissipation of energy is not used with respect to all the methods of interference, the measures intended for automatic stop of the part of machine producing hazard, before the hazard situation occurs as a result of accidental start-up, have been applied
26.	Measures preventing accidental operation to control components and preventing the effects of the unexpected operation of these devices have been applied
27.	Equipment components for collecting and processing of data connected with safety are designed and configured in a manner minimising the possibility of their initiation of start signals
28.	Drives control elements were suited and applied in such a way that they cannot change their status as a result of external impacts or as a result of power supply disturbances
29.	Drives control elements are located in closed housings to prevent their start-up by unauthorised persons
30.	In the design and construction of the control system of the machine, the primacy of the switch off/stop function over the switch on/start up function has been provided
31.	The permanence of the switch off/stop conditions were provided by means of locked or key-switched device controlling the stop, maintaining the signal of permanent stop until it is changed manually
32.	The permanence of the switch off/stop conditions were provided by means of a lockable selector switch with a clear and unambiguous position indication used for maintaining the signal of permanent stop until it is changed manually
33.	The permanence of the switch off/stop conditions were provided by means of a lockable cover, which when locked forces the switch off/stop status on the manual stop control element
34.	The permanence of the switch off/stop conditions were provided by means of a movable guard, which from the very moment it is opened, forces the switch off/stop status on the manual stop control element
35.	The permanence of the switch off/stop conditions were provided by means of
36.	Stop control devices unambiguously indicate the switch off/ stop status
37.	Stop control devices reliably remain in the switch off/stop condition
38.	Stop control devices equipped with the device protecting the maintenance of the switch off/stop condition upon the removal of this device do not cause the re-initiation of the start-up signal
39.	Protective equipment has been applied in order to implement the function of permanent stop according to the risk assessment findings
40.	Mechanical disconnection devices have been designed, suited and applied, and when necessary, are supervised in a manner ensuring the disconnection of movable parts from the machine drives
41.	Protective devices of movable parts are of sufficient mechanical strength and resist the forces resulting from the machine start-up
42.	If the protective devices of movable parts are not of sufficient mechanical resistance to the forces resulting from the machine start-up, the device locking the machine movement until the protection stop has been applied
43.	If basic measures for preventing accidental start-up are practically impossible to apply, then the supervision of stop conditions and provision of automatically initiated stop in case of detection of conditions (or initiation of) unexpected start-up have been provided

Persons performing the assessment of the measures preventing accidental start-up							Date of the assessment
Conclusions from the assessment

Emergency stop device assessment form

Logo of the project TeSaMa		Form symbol XXX		Machine ID XXX-XXX				Form date (date when assessment of safety measures addressing mechanical hazards started) xxxx-xx-xx
Machine name, type and location			Installed emergency stop devices
Emergency stop device assessment (according to PN-EN ISO 13850:2012)
Item	Requirement				Requirement fulfilment		Notes:
					Yes or Not applicable	No
1.	Emergency stop function is always available
2.	Emergency stop function is always effective
3.	Emergency stop function always overrides other functions in all work modes of the machine
4.	No start signal is effective with respect to actions stopped by the initiation of performance of emergency stop function, unless it is reset
5.	Emergency stop function is not used as a measure substituting safety functions performed by technical protective measures
6.	Emergency stop function does not impair the effectiveness of protective devices and other devices performing safety functions
7.	Emergency stop function upon activation of the control element properly causes the stop of movements and actions of the machine presenting hazard (by means of selection of an optimal delay value, function category, adequate stop sequence)
8.	Emergency stop function does not require the operator to take into consideration the effects of such stop
9.	Emergency stop runs according to 0 or 1 category
10.	Sending the emergency stop signal is sustained until it is reset manually
11.	Resetting the emergency stop function is possible only in the place of its initiation
12.	Resetting the emergency stop function does not start up the machine
13.	Restarting the machine is possible only upon resetting the emergency stop function in any place that it was initiated
14.	Parts, devices and elements used to perform the emergency stop functions are well-suited, mounted, connected with each other and secured ensuring the correct operation in expected conditions of use and with expected environmental impact
15.	The control elements in the emergency stop device are: mushroom buttons, wires, cables, bars, handles and in special applications pedals without guards
16.	Emergency stop device has been placed on each control station, unless the risk assessment indicates that it is not necessary
17.	Emergency stop devices are easily accessible
18.	Emergency stop devices can be activated by the operator or other persons
19.	The measures preventing accidental start-up of the emergency stop device do not impair its availability
20.	Emergency stop devices comply with the rule of effective opening with mechanical locking
21.	Emergency stop control element is red and, if possible, the background behind the control element is yellow
22.	In case of use of the wires or cables requiring the improvement of visibility, the flags or other solutions were applied
23.	In case of use of labels, an appropriate IEC symbol was used
24.	In case of using cables or wires as emergency stop control elements the following were taken into consideration: deflections necessary to initiate emergency stop, maximum deflections, minimum distances from the next object in its surroundings, ensuring appropriate visibility for the operator, necessary force and its direction required for activation
25.	The solutions preventing the hazards caused by a break or disconnection of cable or wire were applied
26.	The measures for resetting the emergency stop devices based on cables or wires are located in places from which their entire length is visible
27.	Operating instructions for resetting of cabled or wired emergency stop devices include the requirements for checking the machine along the entire length of the cable or wire

Persons performing the assessment of the emergency stop device							Date of the assessment
Conclusions from the assessment