Improper Use of a Jack Resulted in Finger Injury

Cause & Consequence

• Moving machinery or material being machined

Incident Location

Drilling unit

Incident Activity

Drilling, workover

Lessons Identified

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.

Incident Recommendations

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.