Leg Pinned and Amputated (KV87)

 

What Happened?

In April of 2018, a car wash worker lost his right leg after getting it pinned between two cars. The victim was wiping down the rear of a car as a co-worker was driving the next car out of the car wash. Witnesses say it appeared the driver of the second car mistakenly hit the gas instead of the brake. The worker was taken to the hospital where it was determined the damage was too severe to repair and the leg was amputated.

Contributing Factors

The driver of the second car had a suspended license.

It was routine for workers to pull the cars forward for wiping while other workers were in the line of fire. 

What Can We Learn?

Tools

Procedures: there was no procedure, process, or policy in place to ensure workers are qualified before operating vehicles.

Questioning Attitude: the 2-minute drill card specifically states “what is the best body position for the task”. There were likely near misses before this event.

Traps

Since the injured worker had completed this work many times before, he fell into the Overconfidence trap by underestimating the risks involved and overestimating the competency of his coworker.

The trap of Distractions likely influenced the driver to press the gas instead of the brake.   

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?