Improper Tool Use - Hand Laceration

 

What Happened?

An Insulator technician received a cut to the right hand while preparing an insulating end cap in a satellite fabrication shop. The technician was separating a sheet metal seam on a piece of insulating stock to allow assembly of an end cap. While separating the seam with a pulling motion using an awl, the awl slipped out of the seam, and the technician’s hand came in contact with the sharp edge of the sheet metal, resulting in a laceration on the right hand. The worker was not wearing gloves at the time of the injury. Six sutures were required to close the wound.

Contributing Factors

Incorrect tool for the task - A cutting wheel in lieu of the awl is the preferred tool for this task.

What Can We Learn?

Tools

The Procedure stated that cut resistant gloves are required while performing this task.

Performing a Self Check before the starting this task would have identified that he was not wearing the proper PPE. 

Traps

Overconfidence may have led him to believe he could safely perform this task without gloves.

Time Pressure could have been a factor and prevented him from stopping to put on the correct PPE.

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?