Who is at fault?

[geniusintraining]

The mfg. should have proper safety controls in place...but ultimately the responsibility lies with the company (fines) that purchased the machine eg: procedures and proper safety controls. ......

Any new piece of equipment should be checked out before anyone works on it or runs it

We had a form NAPER (no idea what it stands for) but Engineering, Maintenance, Safety, Management and an Electrician had to sign off on it, we had a meeting at the machine and went through many different possible scenarios

I think its managements fault

 

[Oakley]

Accidents are serious ... but have to be learned from.

What is the root cause(s)?
What is the corrective action(s) to ensure that this doesn't happen again?

What I see so far is:
1) Training
2) System Design
3) Improper job instruction

I'd be very concerned that a new program has been installed without proper checks. Was there a source code review done on this new program? Was the only change for disabling the outputs? How do you know?

Until the accident is fully investigated by properly trained investigator(s), then a false sense of security is felt by all. Proper investigation and causal analysis is crucial. Proper corrective actions need to be made and documented.

Just remember ... blaming someone doesn't prevent the accident from recurring. Forget blame, focus on the dangers and preventative actions.

 

[OZEE]

Well said, Oakley.

A PLC program change will NOT prevent this from happening again -- and you should NEVER count on a PLC to provide personnel safety! A PROPER lockout system and program should be in place. And an override switch and "locking outputs on PLC" are NEVER included in PROPER lockout...

 

[plcisgreat]

I agree with Oakley.
I believe it is Maintenance Supervisors responsibility that his maintenance crew follow standard procedures for setup and maintenance. Not only is he fortunate for not losing any limbs but lucky that he still has a job. Not performing a lock out tag out is a serious strike on your record. The lock out tag out procedures are either not effective or they need to be improved. Should have been at least two lockouts on the machine. One for a supervisor and one for the maintenance man that is working on the machine.

 

[mrtweaver]

I have read and fully understand all that has been said here and do wholeheartedly agree. As I have told interviews and management alike I dont have all my proper appendages in all the proper places from being stupid. As has been said here time and time again one of the most important things is lockout tagout along with proper training. And I have tried to stress this to management instead of just doing the blame game. unfortuneately it seems to fall on deaf ears. I have got the usual well we will do more training when the budget allows, the manufacturer has made changes to make the machine more safe, and the override key has been taken away from that mechanic. To me this still is very serious because again like has been said it lulls a false security. There are several times when doing rapairs and adjustments and change overs on the machine that this type of bypass is required and there are inherant dangers. So I would think this training should be top priority and more so since the accident. If the rest of you posters dont mind I would like to print the contents of this post for the next safety meeting. To me it seems like lets blame, say its fixed because the oem says so, and move on. To me, and I have been a part of many safety commitees, there is still a lot more to do. And it is frustrating that it does not seem to be getting done. Also like one of the posters has said I use my own lock and key this way I know what is done and I ensure all sources of energy have been removed and I always take and check things before I start work on it. yes it takes me longer to do the tasks then someone else but I dont give a darn it my life and it is in my hands.

 

[curlyandshemp]

I recently had an event that I would like to ask the experts on this site how they view it and how they think the outcome should be.

A machine that was designed overseas has electrical and pneumatic controls. It is clearly labeled with all the safety warning. There is also a keylock to override some of the safety devices.

Issue: Mechanic working on machine. Has to make an adjustment to a set of shears. Opens the doors but has the key switch enabled. Pushed estop and proceeds to make adjustments. A wrench falls on a sensors activating it. The stored up residual pneumatic pressure caused the shears to active causing the mechanic to require 23 stitches in his hand. Lukily did not loose anything.

Manufacturer of machine noted that during the routine in question the outputs were not locked out on the PLC. All other times they were but not this time. They send in a revised program.

The safety committee put all the blame on the mechanic. Stating the following: Mechanic did not have machine properly locked out, mechanic had safety key system enabled, mechanic did not remove all stored energy.

While I do see the companies point I dont think it fair to place all the blame on the mechanic. I beleive the mfg should also have been mentioned in the report being as they did not have the outputs locked out during that step in the process.

So in a case like this where do you draw the lines of whose at fault and what to report?

Just curious. Thanks and have a great and prosperous new year.

The air supply should also have a lockout switch.

Was a PSR performed on this equipment?

 

[Marshy]

Issue: Mechanic working on machine. Has to make an adjustment to a set of shears. Opens the doors but has the key switch enabled. Pushed estop and proceeds to make adjustments. A wrench falls on a sensors activating it. The stored up residual pneumatic pressure caused the shears to active causing the mechanic to require 23 stitches in his hand. Lukily did not loose anything.

Although I don´t agree pushing in an estop is a safe way of isolation, why does the overide key overide the estops?

 

[clank]

I agree proper lockout tagout and training are important but it is only 1 layer of protection. But ultimately somebody may forget or does not make to take time to lockout. The company has to show due dilegance and incorperate safety controls on the door that was opened by mechanic to do his work. Door switch incoperating 2 channels to safety relay (double redundancy) and bring this piece of equipment up to at least a catergory 3 safety compliance. Mechanic or operator opens door or doors power is removed and dump valve opens (thru double redundancy)= no injuries. You can have all the training in the world and people sign off on this training and an accident happens ultimately the company is still responsible because the proper safety controls were not put in place.

 

[JesperMP]

I cant believe that I read this.

There have been several posts in this thread that I dont agree with, yet I havent found it worth it to argue against them. But this post is so blatantly wrong that I cannot remain quit.

I agree proper lockout tagout and training are important but it is only 1 layer of protection.

You dont understand that service disconnects are the basis of the personal safety because they are universal, simple, efficient, and reliable.
Universal because there must _allways_ be service disconnects.
Simple because there are far fewer components than in 'active measures'
Efficient because they act directly on the dangerous force(s).
Reliable because of the simplicity.

Door switch incoperating 2 channels to safety relay (double redundancy) and bring this piece of equipment up to at least a catergory 3 safety compliance.

Such active measures should be used for frequent access to the dangerous area, like inserting pieces into a press. Not for maintenance or repair work. If possible, the machine should be designed so that it is not necessary at all to apply active measures. So, there must allways be service disconnects, but not always active measures.

You can have all the training in the world and people sign off on this training and an accident happens ultimately the company is still responsible because the proper safety controls were not put in place.

Do you really argue that a signature means nothing ?
By law, when the company has done everything by the book, and people sign off that they have had the necessary training, then these people really ARE responsible for their own safety. It is similar to getting a driving license.

 

[leitmotif]

Here in USA most worker compensation if not all - not positive - is a no fault insurance so they cover for job injuries regardless of who is at fault. Yes employee can break all safety rules get injured and workers comp will cover it.
Basically - if work related they pay.
Know of cases where they paid for gonorhea and for a pregnancy.

Seems to me all this talk about fault does not matter one whit because
1. worker comp pays anyway
2. Emphasis of a good company with good management is on accident prevention not fault finding after the fact. Bad management is always looking for who to blame and for sure it is NEVER management or so they falsely think but then they are ostriches anyway with heads in sand or they have severe rectal cranial inversion.
3. As I said in previous post and as a few have mentioned an accident should be followed up on to determine what went wrong and
HOW DO WE ENSURE WE DO NOT DO AGAIN.
4. With almost any accident there is human error

Dan Bentler

 

[OkiePC]

Here in USA most worker compensation if not all - not positive - is a no fault insurance so they cover for job injuries regardless of who is at fault. Yes employee can break all safety rules get injured and workers comp will cover it.
Basically - if work related they pay.
Know of cases where they paid for gonorhea and for a pregnancy.

Seems to me all this talk about fault does not matter one whit because
1. worker comp pays anyway
2. Emphasis of a good company with good management is on accident prevention not fault finding after the fact. Bad management is always looking for who to blame and for sure it is NEVER management or so they falsely think but then they are ostriches anyway with heads in sand or they have severe rectal cranial inversion.
3. As I said in previous post and as a few have mentioned an accident should be followed up on to determine what went wrong and
HOW DO WE ENSURE WE DO NOT DO AGAIN.
4. With almost any accident there is human error

Dan Bentler

In addition to Dan's excellent view on this.

A phone call to OSHA can ensure that you have the ability to make it right or make them pay. Your friend with the disfigured hand needs to be paid for their neglect...with a safe work environment first and foremost.

Lock out tag procedures must be designed and implemented by law for any machine capable of this type of injury.

Make sure the powers that be understand this and that they need to take human injury $eriou$ly or be hit where it hurt$.

Paul

 

[leitmotif]

Little more on Worker Comp
Earliest was 1913 I forget which state back East I think.

OSHA and state OSHA type programs have nothing to do with Worker Comp that is generally a state program with exception of Longshore and Harbor which is Federal.

In Washington and Oregon your doctor files the initial claim for you.
You have the choice of physician. Your employer has no say at this stage. You do not even have to tell them.
OSHA and company policy may require you to report the accident but they have no say so with respect to Worker Comp.

If worker comp accepts claim then they start paying medical and if you are off work lost time.
Your employer
-- cannot discipline you for filing a claim
-- does have appeal rights but that is done well down the process - generally employer appeals to worker comp are not an effective use of time or money.
What Worker Comp decides is what goes and that is that.

For sure if you just gotta hurt yourself do it at work best medical insurance going.

Worker Comp is a real good deal but you never want to cheat them either as employee or employer - they will go after you. Supposedly Ore Worker Comp garnished wages when they were able to prove a claimed broken arm actually happened at home.
A fatality I investigated where employer did not believe in Worker Comp was fully paid for by WC including flying casket home to Texas. WC then started having real nasty conversations with employer which eventually put him out of business. I got a standing ovation from area loggers (some of them I had shut down) for this "thank you for stopping him killing our kids".

Dan Bentler

 

[Oakley]

Dan,

Thanks for the insights to Workers Comp. But this thread started as an "Accident Investigation" and who is at fault. I would stress that WC is not to be treated as traditional insurance, but rather that if an accident were to occur, the subject would be taken care of. I like our philosophy at work ... we want you to go home in the same condition you came to work - alive and well.

I hate the "fault" condition, but it sometimes pokes it's ugly reference into accidents.

Like I stated prior, don't look for fault, but rather look at root cause(s) and countermeasure(s) to implement to keep the same situation from happening again. Placing blame or "fault" just promotes an adversarial workplace

 

[leitmotif]

I fully agree with you and said almost same words several posts ago.

If you want to get to the truth / facts of the matter then you have to avoid fault. At Boeing I had a couple cases where a guy said if I tell you the truth someone is gonna get fired. So I promised confidential and found out the truth / facts. Too long to go detail here no one got fired.

Dan Bentler

 

[Bob A.]

The federal law clearly states that "Lock Out, Tag Out, TRY OUT" is required. That is three clearly defined steps! Anything less is a violation of OSHA regulations. PERIOD!