[Hallb-engineering] Fwd: Lesson Learned "Severe Finger Laceration during Machine Shop Operations - Argonne National Laboratory"

Douglas Tilles tilles at jlab.org
Mon Jan 4 12:04:22 EST 2016

----- Forwarded Message -----
From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Monday, January 4, 2016 12:00:07 PM
Subject: Lesson Learned "Severe Finger Laceration during Machine Shop Operations - Argonne National Laboratory"

Jefferson Lab Lessons Learned : Print Lesson 
	Severe Finger Laceration during Machine Shop Operations - Argonne National Laboratory 
Statement of Lessons Learned 
Complete and adequate guarding of machine tools is necessary to protect even skilled employees.  Any momentary distractions, when working with an unguarded blade, can result in serious injury.  Be aware that unguarded hazard complacency, whether from high skill levels, past practices, perceived time pressures, incomplete review and analysis of operating configurations, creates a hazardous condition. 
Discussion of Activities 
On August 13, 2015, a repair machinist placed a three-inch heavy-walled steel pipe on a metal-cutting band saw.  He turned the machine on and noted that the blade was 'jumpy' with an unusual sound coming from the chip auger to the right of the table at the point of cutting operations.  The repair machinist leaned over the table to investigate and his left hand slipped forward into the machine's blade resulting in a near amputation of the left index finger.


The repair machinist was transported to a nearby hospital emergency room for further evaluation and treatment.  The injury resulted in a bone fracture and digit nerve damage requiring surgical repair. 
1)      Periodic inspections did not identify inadequate guarding conditions.  Monthly safety inspection tours never noted any guarding deficiencies.  A previous inspection, conducted by non-shop personnel noted guarding deficiencies but, if corrected, guarding was not in place when the incident occurred. An inspection conducted in 2013 did note guarding deficiencies but recommendations only addressed the deficiency on the right side of the cutting point.  

2)      A handwritten request for repair of hydraulic and chip brush issues had been given to the foreman by the machine owner prior to leaving on an extended absence.  The note did not identify any guarding deficiencies, nor was the machine placed out of service.

3)      The saw was operating when the senior repair machinist leaned over to investigate the unusual sound. 
Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only.

1)      All machine saws were removed from service pending a guarding evaluation to be conducted by the Subject Matter Expert. 

2)    A visual record of each saw, including documenting the correct and complete installation of all required guards, is required.

3)      A written analysis of each operators qualifications is required to assure consistency and compliance with work planning and control requirements. 
JLab Preventive Measures 
(Jefferson Lab's Subject Matter Expert has read and approved this lesson.)


In accordance with ES&H Manual Chapter 6121 Machine Tools: All Jefferson Lab machine tools are considered inherently risky. Jefferson Lab has determined that use of a machine tool carries an unmitigated Risk Code 3.  An Operational Safety Procedure (OSP) is written for each machine tool and read by machine operators prior to use.  OSPs are reviewed and approve to assure compliance with Occupational Safety and Health Administration (OSHA) regulations and American National Standards Institute (ANSI) standards. Operator's Manuals are also reference in OSPs and during training. 
1/4/2016 11:43:25 AM by Bailey, Mary Jo 
Submitted to those current in Lock, Tag, and Try and Forklift Operators 
Summary 	Lesson ID: 	926 
	Status: 	OK 
	Doc ID: 	2016-JLAB-926 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	1/4/2016 11:39:05 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	1/4/2016 11:43:25 AM 
	Source: 	DOECRD 
	Location: 	ANL 
	Cost Savings: 	
	Contact: 	J. Benkert, jbenkert at anl.gov , (630) 252-4335 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

    * DOE - No Guard1 Pic.jpg 
Hazard Issues 

    * Machine Tools 

    * SAF104: LOCK, TAG, AND TRY 

    * *Division Safety Officers (DSOs) 
    * *Safety Wardens 
    * *DOE Notification 
    * *ESH&Q Liaisons 

Do you have a lesson learned you would like to contribute? Contact the Lesson Learned Coordinator .

More information about the Hallb-engineering mailing list