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

• Lost Time Injury (LTI): Stored Pressure Release – Crewman Lost An Eye
• Don’t Put Your Finger In The Wrong Place: Failure To Isolate Equipment Causes Serious Finger Injury
• Serious Finger Injury During Valve Installation