Two employees, a foreman and senior operative entered the cubing area of a block plant following the appropriate safe system of work (SSOW); no specific maintenance tasks were being performed at this stage.  The horizontal banding machine, which is the first in the process to apply straps to secure the product, had faulted with an error message on the control panel display.

Both employees entered the area under safe isolation, including Fortress Interlock Keys.  One employee brushed passed the end blocks, causing one to fall onto the conveyor where the other employee was stood with his hand at waist height on the conveyor.  The block landed on his finger causing an injury which required medical treatment including glue to close the wound.

KEY FINDINGS

• PPE - The Injured was wearing the correct PPE including gloves.
• Training - Both employees are experienced and competent to operate the whole factory process.
• Compliance - A Take 5 had been completed before accessing the area to investigate.
• Risk assessment - Ensure suitable risk assessment of surroundings is carried out and observation of potential hazards. 
• Supervision - Ensure periodic supervision is carried out of all employees and contractors on site.

HOW COULD THIS HAVE BEEN AVOIDED

• Investigate and rectify the cause of any faults / error messages. 
• Review the requirement for a support to be used and added onto the top of the products when working near the unsecure materials. 
• Remain aware of surroundings and any potential hazards from moving materials during a part of the process where they are not secure.

KEY REVIEW POINTS

• Eliminate / reduce the need to interact with automated machinery where possible. 
• Carry out a review of the SSOW and see if any improvements can be made when inside the area with the machinery. 
• Carry out a point of work risk assessment (Take 5) before a task to ensure all hazards and risks have been identified and necessary precautions are in place.