What happened?
Technician was working on unbolting the housing of a hot tap machine using the open end of a combination wrench, (due to the location of the bolt, technician stated he was unable to use the box end of the wrench), when the wrench slipped off of the bolt striking the technician in the upper lip causing a laceration. The technician was transported to an occupational medicine facility and he received two sutures in his lip. This incident resulted in a recordable injury.
What went wrong?
The technician had performed the task so often it became a routine task and he did not fully recognize the potential hazards of pulling on an open ended wrench while placing himself in the line of fire. Although a Shop Job Safety Checklist was completed, there was no consideration given to line of fire hazards and mitigations.
How do we Prevent from Happening Again?
Identify and discuss potential line of fire situations and recognition of the hazards of routine jobs. Discuss the importance of performing a thorough Job Safety Checklist/Job Hazard Analysis.
What actions do I take?
Immediately review this Safety Alert with all technicians and shop employees and discuss the prevention measures listed above. Review the "Line of Fire Top 10" presentation with all field technicians and shop employees and discuss how to effectively identify hazards (focusing on routine job hazards) during the Job Safety Checklist(JSC)/Job Hazard Analysis (JHA) process.
Verify through auditing of shop and field tasks that employees are consistently identifying line of fire hazards and routine task hazards during JSC/JHA completion.
