ACCIDENT INVESTIGATION CASES AND SOLUTIONS

Case No. 1

A warehouse employee was in the act of removing a part from the top of a storage bin. To reach it, he climbed on a wooden container instead of getting a ladder available for this purpose.

While standing on the edge of the container, it began to tip. The employee, trying to check his fall, grasped for the top of the bin with his left hand. As he did so, the ring he wore on his ring finger became caught on the end of a bolt, damaging the finger so badly that it had to be amputated.

What could have been done to prevent this accident? Similar accidents?

Case No. 2

A maintenance worker was in the process of changing the dies on a metal parts punch press. While removing the bottom die, the punch press was activated and the man's right hand was crushed. The man's fingers were so badly damaged that the index and middle fingers had to be surgically amputated.

The operator of the machine had inadvertently leaned against the start button of the machine while observing the maintenance worker changing the dies.

What could have been done to prevent this accident? Similar accidents?

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Accident Investigation: Solutions
Case No. 1

Questions that should have been raised:

  1. Is there a company rule prohibiting the wearing of jewelry at work?
  2. Were there ladders available within the storage area?
  3. If so, was it too big and cumbersome or not the right kind for the job?
  4. Why was the wooden container in the area? Is there a problem with housekeeping?

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Possible Solutions:

  1. A rule prohibiting the wearing of jewelry at work could be instituted. Better training on the hazards of wearing rings would help.
  2. Availability of a ladder in each aisle of the storage area would make one always handy and thus more likely to be used.
  3. Better housekeeping would help since the wooden container the employee stood on was probably not in its proper place.
  4. The use of safety posters might also increase awareness about a potential problem.

Case No. 2

Questions that should have been raised:

  1. Were there any written rules or procedures concerning the changing of the dies?
  2. Why was machine not tagged and locked out?
  3. Why was the operator able to activate machine by merely leaning against the start button?

Possible Solutions:

  1. Establishing a written procedure for the changing of the machine dies by maintenance personnel. This could include, but is not limited to:
  1. Implementing a "tag out-lock out" policy anytime dies are to be changed or work is to be performed on a machine.
  2. The placing of a block of wood or other similar barrier between the ram and the platen.
  1. Installation of protective covers or a recessed start button so that merely leaning on the machine start button will not allow the machine to activate.
  2. A machine design feature which includes a sequential startup procedure would eliminate premature machine operation if the start button is engaged.

Remember, don't be satisfied with the easy solution. Don't think that you have to single out the one and only factor that caused the accident. Such a single cause usually does not exist. There are always a number of contributing factors and these too should be brought out.

This information has been developed from sources believed to be reliable. However, since it is a general guide to safety, compliance with all federal, state or local laws and regulations is the policyholder’s responsibility.

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