At 7:35 a.m. on March 19, 2018, an employee and coworkers were disassembling a blowout preventer (BOP). During disassembly, the employee reached down toward the bottom of the BOP to investigate a blockage. The BOP dropped and struck the employee's right arm between the wrist and elbow. The employee sustained a laceration and fracture and was hospitalized.
No contributing factors known.
What Can We Learn?
The employee should have used a Questioning Attitude to consider the consequences of his actions if performed incorrectly as opposed to the likelihood of it going wrong.
By using a Peer Check the employee would have checked to confirm that the BOP was stable and ready to be investigated due to blockage.
He fell into the Overconfidence trap by overestimating his knowledge of the security of the BOP and underestimated the risk involved in investigating the blockage.
The employee might have experienced Time Pressure by feeling a sense of urgency that pushed him to move swiftly as opposed to checking the security of the BOP.
Ask the Right Questions