Guard Removed (KV102)

 

What Happened?

At 1:35 p.m. on January 31, 2017, Employee #1 was welding together intermediates which came to him in eleven pieces (one upper shell, one lower shell, one divider and eight flange pieces). After Employee #1 was done welding the parts together, he used a Makita Angle Grinder with a 7 x 5/8 inch wheel to clean/grind the flange and inlet. Based on interviews with co-workers, Employee #1 was using an angle grinder without a guard in the welding department. The angle grinder kicked back, cutting his leg. According to employee statements, Employee #1 was sitting down on a short stool with the angle grinder between his legs holding it upside down, which is the incorrect position to perform the task. 

Contributing Factors

The report indicates the workers around him noticed him operating the tool without the proper guard. Coaching from our peers will help eliminate these error likely situations.   

What Can We Learn?

Tools

A Self Check would have helped the employee identify the guard missing from his angle grinder as he would have used the S.T.A.R. method to properly perform his work (Stop, Think, Act, and Review).

Operating a grinder or hand tool that is missing a guard could be identified by using a Critical Step Check before work starts. Using the S.A.F.E. (Summarize, Anticipate, Foresee, and Evaluate) acronym within the Critical Step Check would have ensured the employee's success in this job. 

Traps

The employee injured was using a grinder without the proper guard attached. He fell into the Overconfidence trap by overestimating his knowledge and underestimating the risks.

  

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?