Line of Fire Injury (KV 142)

 

What Happened?

While disassembling a 24” check valve, a maintenance technician’s finger tip was struck with a sledge hammer.

He was working with another technician to remove the valve clapper pin.

At the time of the event, the employee was holding a drive pin (approximately 1” x 14” long) while another technician struck the pin with the hammer. The hammer glanced off the pin and struck the technician’s finger. Stitches were required to treat his injury.

Contributing Factors

There were no contributing factors known.

What Can We Learn?

Tools

There was a Procedure in place for this work activity. It required a stand off tool be used to keep the holder’s hand out of the line of fire. 

A Self Check from either of them would have caused them to stop, & think about what they were doing.

Traps

Both of these employees were Overconfident, placing too much faith in their abilities. Their overconfidence also impacted their perception of the risk associated with this task.

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?