High Potential To Death

Safety Incident Topic: High Potential To Death
Location Of Incident: Geel, Belgium
Date Of Incident: 10th, April 2002


Brief Account Of Incident
· Cover plate of the electrical connecting box was removed to enable motor removal from equipment.
· Removal of cover plate created sharp edge that made contact with the lifting strap.
· During reinstallation, the workers experienced problems to position the motor and had to manoeuvre it to enable reconnection.
· The lifting strap was cut over sharp edge of the connecting box.
· The motor fell down on the leg of one of the workers.A second worker jumped away and experienced a slight cut.
· The lifting chain caught the motor and kept it hanging in the air and prevented the motor from falling on the next platform 2 m down.

What Went Wrong
· The lifting works were not stopped to evaluate the situation at the moment the job was perceived to be more complex than initially anticipated.
· The sharp edge was not noticed (was covered with plastic bag) and so the risk was not seen.
· A lifting strap was used that was overdue on approval.

What Went Well
· Medical treatment and follow-up.
· Quick response from mechanics involved to safely position motor.

Lessons Learned
1· Lifting training is needed that covers how to deal with sharp edges.
2· Evaluate who should be trained to do (manual) lifting works.
3· Improve warehouse storage process to have sufficient approved safety material available.
4· Evaluate what ideas can be copied from TAR’s during a smaller stop (eg container with safety material in unit).
5· Evaluate need for a plant-wide procedure/checklist for doing (manual) lifting works.
6· Evaluate what ideas can be copied from TAR’s during a smaller stop (eg container with safety material in unit).
7· Evaluate need for a plant-wide procedure/checklist for doing (manual) lifting works.