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Hydraulic sample extruder - finger laceration - DEV imca
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Hydraulic sample extruder – finger laceration

What happened?

Whilst using a hydraulic sample extruder in a laboratory, the technician caught and injured his finger between the Shelby tube and extruder ram while trying to stabilise the dolly.  The incident resulted in a lost workday case.

What were the causes? What went wrong?

The investigation identified the following contributing factors:

  • Training – insufficient task training and competence assessment;
  • Supervision – ineffective supervision;
  • Risk Assessment – the task risk assessment did not consider the equipment limits and functions or advances in technology, therefore not all the hazards and associated risks were identified or controlled;
  • Design – the sample extruder design is dated and does not consider human factors or ergonomics;
  • Line of Fire – the technician placed his hand between the moving hydraulic sample extruder ram and Shelby tube.

Lessons learned

  • Employee training and competence assessment, together with the appropriate level of supervision, is essential;
  • Risk assessments and work instructions should be current and periodically reviewed to take account of new information, changes in technology and legislation;
  • A standardised hydraulic sample extruder design / type and use would be central to the reduction of incidents of this sort.

Actions

  • Improved employee training, competence management and supervision requirements;
  • Reviewed and revised equipment and task risk assessments;
  • Improved signage and labelling, start/stop controls and added guard for moving parts / shear point;
  • Standardised hydraulic sample extruder design / type and use across the company;
  • Develop common operating procedures for this equipment.

Members may wish to refer to

Safety Event

Published: 24 July 2020
Download: IMCA SF 22/20

Relevant life-saving rules:
IMCA Safety Flashes
Submit a Report

IMCA Safety Flashes summarise key safety matters and incidents, allowing lessons to be more easily learnt for the benefit of all. The effectiveness of the IMCA Safety Flash system depends on Members sharing information and so avoiding repeat incidents. Please consider adding safetyreports@imca-int.com to your internal distribution list for safety alerts or manually submitting information on incidents you consider may be relevant. All information is anonymised or sanitised, as appropriate.

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IMCA makes every effort to ensure the accuracy and reliability of the data contained in the documents it publishes, but IMCA shall not be liable for any guidance and/or recommendation and/or statement herein contained. The information contained in this document does not fulfil or replace any individual’s or Member's legal, regulatory or other duties or obligations in respect of their operations. Individuals and Members remain solely responsible for the safe, lawful and proper conduct of their operations.