How could you prevent a similar incident:

This case demonstrates not only the importance of having a suitable and sufficient risk assessment for any task with a significant risk (in conjunction with a safe system of work or a standard operating procedure). It also shows how with or without these systems, when management are aware of unsafe practices going on in their workplace and allow this to continue unchecked, this can lead to large fines being imposed, when a serious incident does occur.

Many organisation still don't see the importance of locking off power supplies, which are isolated for maintenance and cleaning of equipment. Numerous serious injuries and even deaths occur each year when power sources are switched back on while workers still have parts of their body in dangerous parts of the machinery. We have personally helped a company, where a mechanic had his arm torn off. 

The mechanic was maintaining a piece of equipment while the operator was on his break. When the operator returned from his break he could not see the mechanic, so the operator switched the machine on. The mechanic was underneath the machine, out of view, with his arms in the equipment, had the isolations been locked this accident could have been prevented!

How can you prevent a similar incident form occurring in your workplace:

• Having robust contractor controls in place using a permit to work system or something similar, will help prevent contractors from carrying out work in a way which would be unsafe or not following your company procedures.

• Carrying out a thorough contractor induction for all contractors who work on your site or on your behalf.

• Carrying out a risk assessment for any tasks with a significant risk, including maintenance and cleaning of work equipment with the assistance of a competent Health & Safety Advisor.

• Developing a safe system of work for each activity including cleaning and maintenance of equipment, especially when fixed guarding or other safety features are disabled or removed.

• Training staff affected, in the safe system of work and risk assessment.

• Assessing competence of staff once they have been trained.

• Ensuring that the safe system of work is followed by all those involved by carrying out proactive audits.

• Ensuring that managers are aware of their responsibilities and they correct unsafe working practices that they observe.

• Do not allow unsafe practices to become custom and practice.

• Properly isolating equipment which is being cleaned or maintained is essential.

• In doing such isolations for maintenance or cleaning interlocks and other safety features of the equipment must not be relied upon for primary isolations e.g. Must not be the only isolation used.

• Any power source whether e.g. electrical or compressed air must be isolated by a valve or switch and if at all possible, a lock should be placed on the isolation point, which prevents accidental re-energising of the power source, if turning on power source early could harm someone.
• The isolations should be checked to ensure it can't be defeated and it is the correct isolation point. (E.g. Trying the on/ off switch prior to any safety devices being removed).

• If more than one person is involved a multi hasp locking system should be used so that each stakeholder in the isolation has to removed the lock before the equipment can be switched back on.

• In the event of an accident, unsafe practice, unsafe condition or near miss, ensure that a procedures are reviewed and amended, if necessary.
• When modifications are made to equipment ensure that existing safety features and devices are not negated or removed. This can be controlled by using a modification control procedure.