Incident
Worker was in the process of checking gauges when suddenly he felt a pulling motion on his right hip and back side. His coveralls had become entangled in an unguarded shaft and were being sheared off. Unable to escape or break free of the drawing motion the worker was able to reach the motor clutch and disengage the equipment, thus ending the ordeal. In the period of time (approximately 15-20 seconds) that initial contact with the rotating equipment, the workers right leg portion ofhis coveralls including his right pant leg and undergarments had been pulled off from the hip down and completely sheared.The worker only received a minor friction burn to the right hip and buttock region, as his hip was against the shaft at the time of shut down.
Cause
The investigation determined the immediate cause of the incident was inadequate guards on rotating equipment. The belt and wheel portion of the motor did have the required guard in place but the center potion had been cut out allowing the crankshaft to protrude out approximately 2 inches past the protective guard. (see photo)
Contributing Factors
- Inadequate Hazard Identification – A complete guard was not in place on the rotating equipment and had not beenidentified.
- Unsafe position for task – Working with in a position that allowed contact with rotating equipment.
- Inadequate lock out and disengaging of equipment – The motor should have been shut in upon realization of inadequate guard, to remove the danger of accidental contact with the rotating equipment. Immediate corrective measures should have followed the identification of the missing guard.
- Inadequate design – The guard had been modified to allow rotating equipment to be outside the protective bearer.
- Congested work area – The area between the gauges and the motor skid (Crank shaft) is very restricted, (24 inches)making the unprotected equipment an even greater hazard.
Preventative Measures
- Operations to immediately identify all inadequately guarded equipment.
- All identified location requiring protective guards on rotating equipment will be required to follow lock out procedure during the working process, to avoid accidental contact.
- All modified guards will be corrected to ensure 100% coverage of rotating equipment is in place.
- Discuss this safety bulletin at area safety meetings.
- Follow up by management to be completed in each working area to ensure compliance, within 2 weeks of notification of this safety bulletin.
