Incident alert

LOCATION:
COMPANY-WIDE
ACTIVITY:
MAINTENANCE & HOUSEKEEPING
SUB ACTIVITY:
N/A
ALERT STATUS:
Normal
DATE ISSUED:
09/12/2009
INCIDENT No:
00248

TITLE
Fingers amputated in lathe
COUNTRY OF ORIGIN
United Kingdom
ACCIDENT / INCIDENT DETAILS
A Maintenance Fitter received serious injuries to his hand whilst working on a component in a lathe. The component was a cylindrical shaft approx 30mm diameter and 300mm long with a key way / groove running down its’ length. The Fitter was dressing / polishing it with a strip of emery cloth, whilst it was rotating in the lathe. It appears that the Fitter was using the length of emery cloth to polish the shaft when his right hand became entangled. As a result he suffered serious injuries to his hand, including the amputation of two fingers and part amputation of a third. The lathe was being run at 2000rpm. The investigation revealed that the fitter had placed his right hand too close to the rotating shaft; he was wearing rubber/cloth type gloves at the time of the incident.
ACCIDENT / INCIDENT IMAGES
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LEARNING POINTS / ACTIONS TAKEN
The primary cause of this incident was misjudgement by the fitter in placing his hand too near the rotating shaft.

1. The Fitter was trained and authorised to use the lathe. Does your site operate Authorised Lists to ensure that only trained / competent personnel are allowed to operate higher risk equipment?

2. The risk of hand injuries whilst using emery cloth to deburr, polish or size components in a lathe is well recognised and documented in the HSE Information Sheet “Accidents at Metalworking Lathes Using Emery Cloth”. Where lathes are used are comprehensive risk assessments and safe systems of work in place? Has the ERIC-P Principle (Eliminate, Reduce, Isolate, Control, Protect) been adopted and all hand finishing work on rotating parts / equipment been eliminated/banned wherever practicable?

3. Where the hand finishing of components on a lathe cannot be eliminated, the risk should be minimised through methods that keep hands away from the rotating component. Can the emery cloth be applied via a robust backing board or a tool post onto which the emery cloth may be placed?

4. As part of the incident investigation it was found that the visor / guard on the lathe was left in an upright position and housekeeping standards in the immediate area were poor. Are all necessary safety features used on equipment? Are cleaning regimes in place and good housekeeping standards maintained in all areas at all times? Are formal routine inspections in place to monitor health and safety standards?

Further information is available in HSE Publications; HS(G)129 “Health and Safety in Engineering Workshops”
and EIS2 “Accidents at Metalworking Lathes Using Emery Cloth”.

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LEARNING POINTS / ACTIONS IMAGES




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