Cause & Consequence
- Moving machinery or material being machined
Lifting, crane, rigging, deck operations
The investigation team found that:
1. The crane would not have activated had the boom been in the rest
2. The crane cab chair arm inadvertently activated the main hoist joystick, whilst the engine was being commissioned at high revs.
3. The work party, toolbox talk, WCC & risk assessment all failed to identify any concerns with the “crane controls” being live and the crane boom not in the rest.
What can we learn from this?
1. There was an ergonomics design flaw with the cab, the chair could physically activate one of the controls. This went unreported for many years - perhaps because people believed it couldn’t cause a problem
2. The change of conditions associated with the crane not being in the rest was not recognised. This meant that the risk of inadvertent activation of the crane was completely missed.
What can we do:
Highlight awareness throughout the work force to;
1. Consider the potential for hidden hazards
2. Be vigilant and aware of any changes imposed by your actions (e.g. moving a chair) and confirm that no hazards have been introduced as a result
3. Challenge the norm – don’t accept “it’s always been like that”