Lessons learned: Always STOP the job if you think it is unsafe

The incident

A crew member was struck on the right lower leg (the shin) by a rebounding hammer.  The incident occurred when he was using the hammer to remove a stainless steel securing pin on the brake band drum of a tugger winch.

He was using the hammer and other equipment to remove a stainless steel securing pin, which was positioned at knee height on the brake band drum. The pin was moving both ways a little, but required more lubrication.  Spray lubricant was applied and was working through the pin mounts.

The crew member was striking the pin out using the hammer; one blow missed the pin, rebounded back and struck his right lower leg, causing a small cut and bruising above the ankle.

What went wrong?

• He was in the line of fire – his leg was so positioned as to be hit when the hammer rebounded.
• The arc / swing of the hammer onto the pin required precision to avoid striking to the side, which resulted in uncontrolled rebound of the hammer in an undesired direction.

What went right?

• A Toolbox Talk and Operational Risk assessments had taken place before starting work.
• All correct PPE was being worn at the time of the incident occurring.

Findings:

What were the causes?

• Immediate causes
  • He hit the pin in such as way as to cause the hammer to rebound in an uncontrolled direction;
  • His leg was in the way.
• Root Causes
  • Inadequate continuous risk assessment
    • The crew member did not identify the potential hammer miss-hit and rebound direction of the hammer during the activity;
    • The risk assessment did not identify the required body position to ensure it was not in the line of fire.
  • STOP Work Authority
    • No “Stop Work” and review the activity was undertaken during the tasks to evaluate the controls being implemented and the possible requirement to improve (by the individual or others).

Lessons learned:

• Deeper and more thorough consideration of what “Line of Fire” can mean – are you in your own line of fire?
• Check with your colleagues before starting – is this safe, could I do this in a better way?
• STOP the job if you think it is unsafe, and put the right controls in place to make sure no-one is harmed.