Cause & Consequence
- Moving machinery or material being machined
WHAT CAUSED IT:
An engineering request had not been raised to address the rotary table pinning misalignment;
A Job Hazard Analysis (JHA/JSA) was not prepared or reviewed for this task;
Discussions took place but a Step-Back 5x5 that included a work stoppage did not occur;
Lack of oversight as the supervisor was performing the task initially given to a floorman;
Failure to understand risk of holding an energized hydraulic jack in place with your hands.
CORRECTIVE ACTIONS: To address this incident, this company did the following:
Instructed employees to stop the job whenever the work changes;
Reminded supervisors to not be involved in tasks they have assigned to others;
Instructed employees to report any engineering difficulties / suggested modifications as soon as possible;
Ensure the clinic and trauma bag are fully stocked at all times and remind employees that the medic does not use sutures without first informing the OIM;
Implemented a better hand protection program and improve supply chain delivery issues.