A maintenance operator sustained a crush injury that had the potential to be far more serious.
The incident involved the use of a pendant within a guarded area to enable functional testing of equipment. Access to the area by the maintenance team was via an Assi key / Castell system to allow adjustments to be made to the chain and sprocket for the long foil arms. As part of the adjustment process in the first entry, the long foil arms had been manually pushed together, meaning they were out of their home position. On the second entry, the team identified the adjustment required and asked for the wireless remote to be brought to them from the control room.
This wireless remote was introduced approximately 2 months earlier to allow functional testing to occur whilst persons were still within the guarded area. To use the remote, the PC controls are switched from operator functionality to wireless for the engineers to complete the work. On switching the PC over, the system re-energised and the long foil arms returned to home position trapping the IP, due to the air supply not being isolated.
Key Findings
- Full isolation of the equipment for maintenance activities was not being performed.
- The isolation register for the site, did not cover all aspects of energy that should be isolated on the Lingl to ensure safety.
- There is no defined or understood way of isolating the equipment to ensure safety.
- Introduction and use of the pendant had not been risk assessed or trained (no management of change process followed.
- There was no planning of the work before the task commenced. The one-minute risk assessment (OMRA) was completed after the event.
- Those involved had not received training and did not foresee the risks when switching the system to wireless.
- It was stated that the culture within the maintenance team was just get the job done.