Key learnings from a high potential incident
HPI OSH Alert #471
Date of incident: 18 November 2015
A sub-contracted Pump Operator was cleaning the cement hopper after a concrete pour. The operator opened the main cover and safety grate and stood inside the hopper to clean out the remaining cement residual.
The operator reached around the cover to pull the water pump lever but slipped and engaged the agitator control.
Once the agitator paddle rotated, it caught the operator’s shin between the hopper and the paddle. The offsider saw what happened and hit the emergency stop button.
As a result of this incident, the subcontractor sustained an open fracture of the lower left leg (Tibia) and several fractures in the left ankle/foot.
Why did this happen?
- The operator entered the cement hopper and put themselves in the line of fire. This was in breach of the contractor’s site safe systems of work.
What will be done do to stop this from happening again?
We can confirm that the contracting company has fully and effectively completed all of the following corrective actions and reviews:
- Subcontractors will not be permitted to operate on site until they can provide evidence of adequate safety management processes.
- Review the application of locking grates on site.
- Review contractor engagement for lower tier subcontractors.
- Review the verification of competency and supervision process for contractors who are short term or infrequent services providers.
- Re-establish the wash down facility in a new location with scaffold access.
- Review the project risk register and update accordingly.
What key learnings can you discuss with your team to stop this from happening again?
1. Operators should never place themselves in the line of fire of moving parts on plant and machinery.
- Does our team have any planned or unplanned work which involves machinery, plant and the possible risk of being caught in moving parts of machinery?
- How does our team identify, assess and control the risks associated with operation of machinery and equipment?
- What should we do to reduce the risk of being injured by moving parts on plant and machinery?
2. Machinery, plant and equipment shall be inspected and maintained in accordance with Regulation and manufacturer’s requirements.
- What is our inspection and maintenance process for items of plant and machinery?
- How do we know that it meets the manufacturer’s schedule for inspection items and frequency plus includes the checking of any interlock or safety switches?
- What are some of the things we need to do when we conduct pre-start checks on machinery, plant and equipment?
3. Operators of machinery, plant and equipment shall be trained and competent plus have the relevant certification where required.
- Do we have any team members who operate or supervise the use of mobile plant and trenchless technology? What training and certification do they have?
- What are the licensing and competency requirements for Mobile Plant Operators and where would we find them?
- How do we verify that any contractors we have working for us have a system in place to effectively manage operator competencies and licences?
If you would like further information about anything included in this HPI OSH Alert, please contact Charis Neumann, Snr OSH Analyst Incidents, (08) 6330 6629