A contract inspector was injured while he was demagnetizing a low-pressure turbine rotor.
The rotor was slowly rotating at the time, and the inspector's foot was caught between the turbine wheel and staging erected around the turbine. He suffered laceration and crushing injuries to the toes. One toe and part of another had to be removed. The original plan to lay the demagnetizing cables on the staging was changed by the inspector to holding the cables over the rotating rotor, which resulted in putting him closer to the hazard.
The control box for the rotor turning equipment was marked with conflicting information, which resulted in turning the rotor in an unsafe direction; down and towards the inspector’s feet, rather than up and away from him.
A pre-job briefing had not been conducted, and potential hazards had not been reviewed.
What Can We Learn?
A Questioning Attitude could have caused him to evaluate the risk associated with changing the established process.
A Self Check would have allowed him to further evaluate his body position in conjunction with the rotor.
The controls being labelled incorrectly created an environment with a higher risk of pinch point injury. (Physical Environment)
The act of holding the cables over the rotor, while maintaining awareness of body positioning was Multi-tasking and not part of the original plan.
Ask the Right Questions