High potential near-miss during equipment testing

The incident occurred during troubleshooting of a heavy duty multi-strand electrical cable. Technicians connected the cable between a metal worktable vice and the rear towing / pull pin of a forklift truck, in order to allow stretching and tensioning of the cable. Once the stretched cable was tested, the tension was released and the forklift truck shut down. The cable was not disconnected from either the worktable vice or the forklift.

A short time later, another employee boarded the forklift truck, started the engine and began to drive away. The cable jerked taught and pulled the metal worktable forward approximately 1 m before warning shouts were recognised and the forklift was stopped.

No personnel were injured and no equipment was damaged. However, the potential for personnel to have been injured and equipment to have been damaged was very high had personnel been at the work table or had the work table been pulled over. At the time of the incident there were a number of costly pieces of electronic equipment on the work bench.

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Findings

The company’s investigation revealed that:

• There were no test procedures for the set-up and use of the forklift for stretching and tensioning the cable.
  
  
• There was no job safety analysis (JSA) addressing actual or potential hazards of stretching and tensioning the cable with the forklift in order to support troubleshooting of the electrical cable.
  
  
• The electrical cable had not been removed from either the worktable vice or the forklift once the tensioning had been completed.
  
  
• There was inadequate communications between employees – no communication took place between the personnel using the forklift for testing and the operator who sought to drive the forklift from the area.
  
  
• The operator who boarded the forklift did not inspect or walk around the vehicle before starting up and driving away.
  
  
• There were inadequate guards or barriers – the forklift had not been secured to prevent access (i.e., no warning signs, labels, the key had not been removed from the ignition, etc.)
  
  
• The testing of the cable was rushed to completion without a thorough review of all aspects of equipment, personnel and process.

Further investigation revealed the following root causes:

• Inadequate leadership/supervision – Proper management of the overall testing process, equipment, and personnel would have prevented this near miss incident. Contributing factors to this root cause include inadequate work planning, inadequate identification and evaluation of the potential loss/hazards/risks, and inadequate or missing documentation (JSA, procedures, and/or instructions, etc.) which would have provided better control of work.
  
  
• Poor communication between peers – No communications took place between the operator and the using department before the operator started the forklift and drove away.
  
  
• Improper motivation – The failure of the operator to visually check the status of the forklift prior to use demonstrated complacency with the dangers and hazards of forklift operations.