DOE reviews injury, investigates, solves … then 3 more injuries

by on July 26, 2012 · 0 Comment POSTED IN: Workplace Safety Network
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Four Department of Energy (DOE) workers were seriously injured during the first six months of 2011 moving heavy compressed-gas cylinders with hand carts.

Each incident triggered a post-accident investigation and recommended procedures to prevent future accidents.

Yet the accidents kept coming; ultimately, three workers suffered severed fingertips and one suffered a compound finger fracture.

The accidents occurred in similar ways – in each case, a compressed-gas cylinder weighing about 160 pounds slipped off a retaining hook when a worker tipped it back onto a cart. In each case, the cylinder pinched a worker’s fingers against the cart – in three cases hard enough to amputate fingertips. (The fourth was a compound finger fracture.)

Safety’s reaction
The DOE studied each incident and concluded:

  • Workers hadn’t been adequately trained. Moving gas cylinders was considered “skill of the craft.” Workers should know or be able to figure out how to safely move them, including adjusting the retaining hooks to seat the cylinder correctly. When debriefing the injured workers, investigators learned each was working intuitively, using what had worked many times in the past. The DOE concluded that workers needed better training on the specifics – and the DOE needed to get better info on safe handling from the manufacturers.
  • Some of the hand carts were unsafe. They were taken out of service. One type didn’t allow workers to see if the hook was seated correctly without standing to the side of the cart.
  • Workers needed reminders to keep their hands from potential pinch points. They told workers to use both hands on the back handles, where the fingers are out of harm’s way.
  • Use two people to move the cylinders when possible. One facility, which suffered two of the four injuries, made the two-person a mandatory, not optional, policy.

Questions to ask
Why were workers putting their hands in pinch points to begin with? Their hands were always safe if they leaned the cart back with their hands on the handles. If “keep hands out of pinch points” was that easy, why didn’t workers do it that way?

The answer could be workers perceived a greater threat – that they needed to stabilize the cylinder-laden hand cart with one hand with one hand on the cylinder. The cylinder could fall and roll, potentially hurting their feet or creating a hazardous leak if a regulator was knocked off.

That was the real problem, and why formal procedures were needed to avoid that necessity. DOE needed to make sure workers felt comfortable adjusting the retaining hooks and correctly identifying whether the cylinder was correctly seated. In an at least one case, DOE decided it was a two-person job.

Bottom line: Workers often tolerate risks they shouldn’t. And if you don’t know about them, you’ll have no way to correct them. Reviewing near-miss data and talking to workers and supervisors – surveying them if necessary – will help you smoke out these unnecessary risks. Otherwise, workers may just wing it.

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  1. July 27, 2012 - 5:17 pm

    This really hit the nail on the head – “That was the real problem, and why formal procedures were needed to avoid that necessity.” Proper training and safety protocols are crucial to maintaining a safe and comfortable work atmosphere. Procedures help to reduce the number of accidents on the job.

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