What to ask when workers risk line-of-fire injuries

by on March 29, 2012 · 0 Comment POSTED IN: Workplace Safety Network

When equipment fails, and someone gets hurt, it’s easy to write the incident off as “one of those things.”

But as safety director, you know it’s important to dig deeper for behavioral causes, too.

Here’s an example: Firefighters conducting a training drill at Sussex County Community College, Hampton, NJ, suffered an equipment failure that led to a serious injury.

Watched for ‘water hammer’
A firefighter was learning how to use a manifold valve filled with high-pressure water. She was instructed to close two valves. She asked if she should close the valves separately to avoid a “water hammer” effect.

Firefighters know to watch for pressure surges (aka, “water hammers”), so it was a good question. She was correctly instructed to close both valves at the same time – just slowly.

Despite correct use and instruction, the 200 psi water pressure caused a catastrophic equipment failure. The manifold failed and split in two.

One piece splintered away harmlessly. But a larger piece shot up and struck the firefighter in her legs and abdomen.

The force knocked her out and she fell to the ground. She suffered a head laceration, severe bruising to her legs, and required extensive physical therapy.

Equipment was defective
In a post-accident investigation, metallurgical testing revealed the manifold’s casting quality was poor. It contained numerous voids and impurities that weakened the aluminum-silicon casting alloy.

Complicating matters: The metallurgical analysts concluded that normal firefighter inspection would not have revealed those defects.

The post-incident investigation also revealed she was wearing the proper PPE: helmet, turnout coat and pants, gloves and boots.

For most safety directors, this would be enough.

But there was also the issue of line of fire. The firefighter was leaning over the manifold as she closed the valves. She was directly in the line of fire when it failed.

Key: awareness of line of fire

Where’s the take-home? In a small detail – her awareness of the risk. She knew closing the valves would cause back-pressure on the manifold. She asked if there was a way to reduce that pressure gradually.

As this case shows, often workers are well aware they are entering a riskier situation. In situations like that, they need to think about line of fire, or other risks they may face at that moment.

They can ask:

  1. What happens if the equipment fails? Workers should always look to remain out of the line of fire. That includes thinking about an equipment failure.In one recent case, one worker was hurt standing too close to a scissors lift when it failed. In another, a bucket fell off a backhoe and tumbled into a trench.
  2. Is there a way to reduce exposure to line of fire? Closing the valves with her body in a different position may have reduced her exposure.It wouldn’t have eliminated all risk – she still would have faced the possibility of getting hit with the second piece.

    But by leaning her body over the manifold, she basically was falling on a grenade when it failed: She had no chance of avoiding an accident. She (and her instructor) were simply hoping nothing would go wrong.

  3. Will my PPE protect me? In this case, it offered some protection. Better to fall with a helmet on than not.But PPE can only do so much. The key is that she was wearing the proper PPE, as should all workers exposed to line-of-fire injuries.

Safety director’s questions
As safety director, you can ask yourself a few questions to help prevent similar incidents:

    1. Are there engineering controls beyond PPE to guard the line of fire? Longer valve handles or extension tools, for example, may have obviated the need for the worker to be so close to highly pressurized equipment.
    2. Are workers looking for signs of metal fatigue during inspections? Poorly manufactured equipment will sometimes show brittle edges and tiny cracks.When equipment prematurely shows those signs, workers should know to call you: You can check for previous incidents with the product.

      Watch out for the tendency to keep equipment in service after a problem has been discovered. It’s easy to say, “There hasn’t been a problem, so that crack doesn’t mean anything.”

    3. Do we know the performance history of the equipment we purchase and already possess? Poorly performing equipment tends to have problems elsewhere, not just at your site.An eye on the news helps. So does an ear to the ground (i.e., are workers and supervisors sharing information with you they know about the equipment they have?)

If problems crop up elsewhere, a call to the manufacturer may let you know how concerned they are about customer service. For example, you can ask whether they’ve solved casting problems involving voids and impurities – and how.

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