Fingers Caught in Machine (KV 193v2)

 

What Happened?

At 11:30 a.m. on June 26th, 2018, an employee was tightening the belts of a wire spooler machine that was not locked out. During tightening, a coworker initiated the spooler and two of the employees fingers became caught in the machine. As a result, the fingertips of both fingers were amputated.

Contributing Factors

There were no contributing factors known.

What Can We Learn?

Traps

It’s possible that both employee were Distracted causing them to lose focus on what they doing and following the proper procedures.

It’s likely that Overconfidence played a role in the incident as both employees have likely done the same thing many times without getting injured.

Tools

By using Effective Communication the employees would have ensured that they were speaking and listening in a way that would have eliminated the error of initiating the spooler while the belts were being tightened.

Were the proper Procedures used by the employee as he did not lock out the spooler while tightening the belts?    

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?