Cause & Consequence
- Moving, flying or falling object
Specific Incident Equipment
No details available.
Failure of company Management System to capture and retain industry lessons learnt.Accepted practice in attaching the rope to the link tilt intermediate stop to the bail arm.Pneumatic operated link tilt system inherently fail-unsafe:When the link tilt is extended to the intermediate position, the link tilt bellow charges to full pressure against the intermediate stop. If the intermediate stops are rendered ineffective the link tilt will extend fully with force and speed.
Remove the rope attached to the link tilt intermediate stops when it is not required. Equipment connected to the link tilt system should not be connected to the bail arm, with the exception of the link tilt chains. Review the design of the link tilt system with the manufacture to seek a fail-safe system.