• Published: 12 May 2011
  • Incident ID: 3157

Thumb Partially Severed in Rotating HVAC Equipment

Cause & Consequence

  • Moving, flying or falling object
Incident Consequence

Incident Location

Drilling unit

Incident Activity

Any Activity Type

Incident Info Source

Fiona Gibson, HES Team, or 01224-334127

Specific Incident Equipment

Twin HVAC (Heating, Ventilation & Air Conditioning) Unit

Lessons Identified

Although the causes of "windmilling" were understood by the Maintenance Group, in this case they showed an inadequate appreciation of the risk.Clear direction is necessary to establish adequate isolation practices for HVAC mechanical systems.JHA should stipulate the requirement for rotating equipment to be stationary prior to removal of guards. Risk perception had eroded over time leading to nonconformance with safe work practices that compromised the integrity of HVAC mechanical isolations. These practices had not been challenged or were tolerated.Provide signage on HVAC doors or guards to highlight requirement to mechanically isolate and verify that fan is not "windmilling" prior to removing guards and doing the work

Incident Recommendations

1…Ensure HVAC equipment is suitably isolated. Both electrically and mechanically……..

2…Ensure Risk Assessment adequately identifies the hazard presented by 'windmilling' blades and clearly states a suitable and sufficient method of reducing the risk whereby the HVAC fan blades are physically prevented from any movement while the maintenance is ongoing………

3…..Challenge “At Risk” behaviours

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