Severe Injury from Rotating Equipment

 

What Happened?

A machinist was using emery cloth to polish a valve plug on a lathe, when his protective clothing became entangled in the rotating plug. He was pulled onto the lathe with his arm wrapped around the plug.  He was lifted completely off the floor, his right shoulder was on the opposite side of the lathe, and his chest was on the valve stem. The machinist used his foot to disengage the drive lever as he was pulled onto the lathe.  He suffered extensive injuries.

Contributing Factors

The employees selection of PPE increased the likely hood of injury but this hazard was not taken into account.

What Can We Learn?

Tools

There was a Procedure in place that required all protective clothing to be designed to “break away” while working around rotating equipment.

A Self Check would have caused him to think about his task further & decide whether he had everything he needed to perform this task safely.

Traps

Time Pressure may have been a factor as cleaning the plug while it was rotating would be quicker than if it was stationary.

The employee may have been Overconfident that he could safely clean the valve plug while it was rotating and without the proper 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?