2009-09-18 Failure to lockout results in hand injury

Safety Alert Type: 
Date of Incident / Close Call: 
Company Name: 
LTN Contracting Ltd.
Details of Incident / Close Call: 

On September 16, Mechanic was asked by Driver to "set the clutch" on a log haul tractor. Mechanic did not have his "starter by-pass" so decided he would have Driver turn the key over to get the clutch to turn over. Mechanic instructed Driver what to do. Driver got into the truck and followed the provided instructions without incident.

Mechanic watched from safe distance and lined the clutch up. Driver was instructed to shut the key off. Instructed by Mechanic, Driver then went under the truck to grease the clutch.

Mechanic then went to "set the clutch" and instructed Driver to get in the cab and push the clutch to release pressure on the clutch. Mechanic had hand and wrench on the nut that would set and lock the clutch in the proper position.

Driver, instead of releasing pressure on the clutch, turned the key and started the engine. Mechanics hand was caught by the flywheel and clutch assembly, causing a cut on the right hand "pinkie" and "ring" fingers.

Driver performed first aid on Mechanic. Mechanic was then taken to hospital for medical attention.

Mechanic received several stitches from the incident.


Contributing Factors:
1. Proper instruction was not understood by Driver because of worksite distractions (other drivers, cell phone).
2. Lock-Out was not properly instructed or used. Once the clutch was in place, Mechanic should have instructed Driver to remove the keys to ensure the engine could not be started. Following "Company Lock-Out Procedures," Driver should have removed the key to ensure the engine could not be started.
3. Proper tools where known, but not immediately available. Alternative method was used, but plan broke down in communications stage (see CF 2).


Learnings and Suggestions: 


1. Workers must keep their mind on the task at hand. When receiving instructions, giving instructions or performing duties, limit distractions such as visitors and cell phones until the task is completed.
2. When performing mechanical repairs with two or more workers involved, the workers should use "Redundant Instruction" where instructions are given by the task leader (the mechanic). The instructions are then repeated by the helpers (the driver) to ensure all workers (task leader and helpers) involved have heard the instructions and know their role in performing the task. Redundant Instruction keeps the mind on the task at hand.
3. Review Lock-Out procedures with all drivers and mechanics.


File attachments
2009-09-18 Failure to lockout results in hand injury.pdf
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