Maintenance was being carried out on a roller on the cross conveyor. A risk assessment and a permit to work had been raised for this operation. The maintenance was being carried out by an officer and an AB.

Whilst loosening the bolts, the IP was holding the spanner in place using the jaw end of the spanner, not the ring end. The spanner slipped and pinched the IP’s hand between the spanner and the roller.

An investigation found that the root cause of the incident was the use of inadequate or improperly prepared tools. The IP suffered a compression injury, bruising and a break in the skin.

• All Risk assessments that require the use of hand tools to be reviewed prior to commencing the task.


• To ensure that the risk of using hand tools is adequately documented and the correct tools have been selected and will be properly employed for the task.