Hydraulic sample extruder – finger laceration
- Safety Flash
- Published on 24 July 2020
- Generated on 22 December 2024
- IMCA SF 22/20
- 2 minute read
What happened?
Whilst using a hydraulic sample extruder in a laboratory, the technician caught and injured his finger between the Shelby tube and extruder ram while trying to stabilise the dolly.
The incident resulted in a lost workday case.
What were the causes? What went wrong?
The investigation identified the following contributing factors:
- Training – insufficient task training and competence assessment.
- Supervision – ineffective supervision.
- Risk Assessment – the task risk assessment did not consider the equipment limits and functions or advances in technology, therefore not all the hazards and associated risks were identified or controlled.
- Design – the sample extruder design is dated and does not consider human factors or ergonomics.
- Line of Fire – the technician placed his hand between the moving hydraulic sample extruder ram and Shelby tube.
Lessons learned
- Employee training and competence assessment, together with the appropriate level of supervision, is essential.
- Risk assessments and work instructions should be current and periodically reviewed to take account of new information, changes in technology and legislation.
- A standardised hydraulic sample extruder design / type and use would be central to the reduction of incidents of this sort.
Actions
- Improved employee training, competence management and supervision requirements.
- Reviewed and revised equipment and task risk assessments.
- Improved signage and labelling, start/stop controls and added guard for moving parts / shear point.
- Standardised hydraulic sample extruder design / type and use across the company.
- Develop common operating procedures for this equipment.
Members may wish to refer to
- Lost Time Injury (LTI): Stored Pressure Release – Crewman Lost An Eye
- Don’t Put Your Finger In The Wrong Place: Failure To Isolate Equipment Causes Serious Finger Injury
- Serious Finger Injury During Valve Installation
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