Furmanite Technician
was using a hydraulic press to remove the spring on a PSV in order to
disassemble it for repair. The PSV was placed into the press clamp to
hold the base for removal. Wedges were then placed on either side of the
PSV spring in order to adapt the spring to the ram of the press (see
photo). The spring was compressed using the press so the adjustment nut
on the spring guide of the PSV could be removed. As the technician was
removing the nut (technician was wearing gloves), he released tension on the
press and the PSV shifted causing the spring to break free and technicians thumb
to be caught between one of the wedges and the press. This resulted in a
laceration and fracture to the technicians left thumb.
Preliminary
Investigation Findings
Primary Root
Cause:
·
Technician did not evaluate the potential risk of placing
hand in the “line of fire” prior to performing the task. ( a tool should
have been used)
Contributing
Factor(s):
·
Technician did not properly secure the PSV in the press
clamp to properly secure it and keep it from moving.
Initial
Actions to Prevent Reoccurrence
·
Discuss this incident with all employees and ensure they
have a clear understanding of risk tolerance with regards to personal safety.
·
Each employee needs to identify hazards that exist or may
exist in everyday tasks and take the necessary steps (up to an including
completely revising how they perform a task and if the machine they are using
is correctly designed to perform that task). If an employee determines
that either the equipment or the method used to perform a task poses a hazard,
it is an expectation that the employee will take the necessary steps to
mitigate that hazard.
Immediate
Actions Required
1.
Immediately share this Safety Alert with all
employees in your respective areas.2. Ensure all employees are aware of hand placement and line of fire when working with equipment that contains residual or stored energy (spring tension)
3. Review all tasks using a hydraulic press or other type of mechanical press equipment and ensure potential risks are identified and mitigated.
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