Whilst using a hydraulic sample extruder in a laboratory, the technician caught and injured his finger between the Shelby tube and extruder ram while trying to stabilise the dolly. The incident resulted in a lost workday case.
What were the causes? What went wrong?
The investigation identified the following contributing factors:
- Training – insufficient task training and competence assessment;
- Supervision – ineffective supervision;
- Risk Assessment – the task risk assessment did not consider the equipment limits and functions or advances in technology, therefore not all the hazards and associated risks were identified or controlled;
- Design – the sample extruder design is dated and does not consider human factors or ergonomics;
- Line of Fire – the technician placed his hand between the moving hydraulic sample extruder ram and Shelby tube.
- Employee training and competence assessment, together with the appropriate level of supervision, is essential;
- Risk assessments and work instructions should be current and periodically reviewed to take account of new information, changes in technology and legislation;
- A standardised hydraulic sample extruder design / type and use would be central to the reduction of incidents of this sort.
- Improved employee training, competence management and supervision requirements;
- Reviewed and revised equipment and task risk assessments;
- Improved signage and labelling, start/stop controls and added guard for moving parts / shear point;
- Standardised hydraulic sample extruder design / type and use across the company;
- Develop common operating procedures for this equipment.