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meady  
#1 Posted : 17 April 2019 09:06:58(UTC)
Rank: Forum user
meady

Hi guys,

I just wanted to ask for some advice regarding an accident.

An employee was using a panel saw to cut material.

All training, machinery checks and inspections, push sticks, Toolbox Talks and signage etc. were in place and carried out correctly. The employee is experienced in the task and uses a panel saw daily.

After cutting some material the employee reached around the back of the panel saw blade to remove some off-cuts by hand.

In doing so the employee's index finger caught the blade (which had not been switched off).

Employee suffered a cut finger and has sinced been signed off work for a week, so Over-seven-day incapacitation of the worker.

Accident investigation was completed with human error the immediate cause.

Has anyone been in similar situations where clear human error has led to an injury?

For the record I intend on submitting a RIDDOR later this afternoon. This is just to gather some advice and experiences from some of my peers.

Thanks

chris42  
#2 Posted : 17 April 2019 09:13:44(UTC)
Rank: Super forum user
chris42

Quote

Employee suffered a cut finger and has sinced been signed off work for a week, so Over-seven-day incapacitation of the worker.

End Quote

Are you sure about that ? Ie hurt finger Monday, signed off Tuesday to following Monday (1 week =7 days), only RIDDOR if not in work the next Tuesday ie day 8. Remember the day of the accident does not count and it is “MORE THAN 7 DAYS”.

Other than that if more than 7 days then yes reportable as it matters not whose fault it is.

Chris

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A Kurdziel on 17/04/2019(UTC)
CptBeaky  
#3 Posted : 17 April 2019 09:20:28(UTC)
Rank: Forum user
CptBeaky

Yes that is reportable. RIDDOR isn't really concerned with the 'How', just the 'What'.

In regards to your investigation you seem to not have asked the question why? Why did the operator go against his training? Why was the saw not switched off? Is this something that is done regularly? I Rarely conclude that 'human error' was the blame.

Without knowing the full details of this accident I would be more inclined to look at whether this is a supervision issue. Was this behaviour turned a blind eye to? Alternatively, I would also be looking at whether the opeator needed to be re-trained. Did the operator have time pressures? However, the first thing I would be looking at was whether there should have been some engineer controls to stop this from happening in the first place.

RIDDOR isn't there to punish you. If you show you are taking the right steps to improve safety you will neer hear back (and probably won't even if you don't). You should be using this to review the risk assessment/SOP of the machine. Obviously it failed and therefore you need to consider why.

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A Kurdziel on 17/04/2019(UTC), Elfin Davy 09 on 17/04/2019(UTC), Dave5705 on 20/04/2019(UTC), jwk on 24/04/2019(UTC)
fairlieg  
#4 Posted : 17 April 2019 10:33:22(UTC)
Rank: Forum user
fairlieg

You seem to be clear on the RIDDOR requirement, as Chris42 mentioned make sure you count the days properly and it is more that 7 days.

As far as advice goes, Human Error for me is the starting point of the investigation as Cpt Beakey suggests.

By concluding that they employee was to blame is fine but you need to understand why it made sense to him to do it that way because if it made sense to him it will make sense to someone else.  Also ask yourself if you blame the person what do you actually fix?

How do you seperate the human from or control the energy that will hurt them the next time they or someone else makes that mistake....

Edited by user 17 April 2019 10:36:44(UTC)  | Reason: Not specified

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Dave5705 on 20/04/2019(UTC)
Bigmac1  
#5 Posted : 17 April 2019 10:45:33(UTC)
Rank: Super forum user
Bigmac1

Im not sure what you are asking!

You know its reportable so whats the question?

stevedm  
#6 Posted : 17 April 2019 10:53:15(UTC)
Rank: Super forum user
stevedm

seems entirely foreseeable to me...have you considered it in your risk assessments?

Hsquared14  
#7 Posted : 17 April 2019 11:47:13(UTC)
Rank: Super forum user
Hsquared14

I was going to say exactly the same as Chris 42 but also as others have pointed out this is a typical accident scenario and very foreseeable.  For that reason I wouldn't necessarily count it as "human error" as it stands I would call it an accident waiting to happen and you need to revisit; risk assessments, training, instructions, and machine controls.  So long as you have counted your dates correctly then yes - this is RIDDOR reportable.

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A Kurdziel on 17/04/2019(UTC)
Steve e ashton  
#8 Posted : 18 April 2019 08:33:54(UTC)
Rank: Super forum user
Steve e ashton

Any investigation process that identifies human error in this case appears to be very deeply flawed. Dangerous machinery? Guard it to prevent contact. So simple it seems to have been forgotten. Guards must protect the careless and inattentive as well as the competent and alert. Simples. Stop blaming employees for management./angineering failures.
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A Kurdziel on 18/04/2019(UTC), Dave5705 on 20/04/2019(UTC), jwk on 24/04/2019(UTC)
David Hicks  
#9 Posted : 18 April 2019 09:09:39(UTC)
Rank: New forum user
David Hicks

To echo previous posts, it is outcome, not cause that is reportable*.  I’ve worked with people in the past who were very “inventive” in hurting themselves but I still had to report the incident.  I put “not reasonably foreseeable” in the description when I thought it was justified and the HSE seemed to agree. However, hand contact with an unguarded blade does sound foreseeable and if it was  “human error” I’d want to make sure my report included the root cause and any further steps to rectify it or I’d be expecting at least a phone call from my local inspector.

*Or potential outcome in the case of a "dangerous occurrence" before someone jumps in…

CptBeaky  
#10 Posted : 18 April 2019 09:56:03(UTC)
Rank: Forum user
CptBeaky

Just to reiterate what everyone else is saying. The reason we have the hierachy of control, and the reason that PPE is the last resort is due to the fallibility of humans.

As a case study, if you will. Recently I had a worker hurt their back moving something that they knew was at least a two man job. This was despite proper training, proper supervision (the supervisor had said not to do it, help would be there soon) and MHE available. When investigating they even admitted that they knew they shouldn't have done it, and it was their fault. The results of my investigation still did not point to human error. We still could have done more.

My investigation actually pointed to a lack of storage room and insufficient MH risk assesment. The object was being stored a long way from where it was needed. The worker was only doing what he felt was right. If we had spotted earlier that the objects were being stored too far away we could have adjusted the workplace and this would never have happened.

Even then there are other things beyong 'human error' that I looked at. Did we even need to use this object? Could it be made lighter? etc.

Whilst we can all agree human error is a cause in many accidents, it doesn't help us prevent it happening again. The scientist in me would suggest human error is as useful as "God did it" when trying to answer a question.

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A Kurdziel on 18/04/2019(UTC), jdc1975@hotmail.co.uk on 18/04/2019(UTC), Dave5705 on 20/04/2019(UTC)
meady  
#11 Posted : 18 April 2019 11:22:46(UTC)
Rank: Forum user
meady

Thanks everyone for the replies.

I did not make it clear in the post that the employee had already been off work for 2 days due to the injury before being signed off for an additional week.

Again, the investigation is not looking to point the finger (no pun intended) but to review if our systems are up to standard, prevent recurrence and rectify any faults.

A third party attended site to inspect the saw following the incident and found no fault, all guarding in place etc. The saw was in good order with all safety devices in place.

The employee himself said he reached around to remove the debris and part of the investigation does cover factors such as work presures, time constraints as well as external factors i.e. any stress or issues in the guy's personal lives. None of these were found to be causing any issues with the employee.

Regarding our risk assessment contact with a saw blade is covered and controls are in place, push sticks etc. This has been reviewed as part of the investigation and the only change is to have refresher training at more regular intervals, we are also looking at putting up safety posters in certain areas to try and avoid future incidents.

I take on board the points raised about human error being the starting point for investigations but surely in some circumstances the responsibility for accidents is with the employee for their actions and going against instruction and training provided?

 

MrBrightside  
#12 Posted : 18 April 2019 12:02:17(UTC)
Rank: Forum user
MrBrightside

Hi Meady,

I'm always one to learn! What does your risk assessment state about removing debris? 

westonphil  
#13 Posted : 18 April 2019 12:20:46(UTC)
Rank: Super forum user
westonphil

Hi Meady,

Did he give a reason for his actions?

Regards

meady  
#14 Posted : 18 April 2019 12:23:37(UTC)
Rank: Forum user
meady

Hi MrBrightside,

Risk Assessment says that the panel saw must be operated in accordance with training provided at all times.

Part of the training says that a push stick should always be used to remove the cut piece from between the fence and saw blade. This includes any offcuts and any debris.

meady  
#15 Posted : 18 April 2019 12:27:11(UTC)
Rank: Forum user
meady

Hi Westonphil,

No none at all, he said it was a stupid mistake and that he shouldn't have done it but gave no reason why.

My guess is that a lapse of concentration, i've even taken light meter readings at the saw to see if lighting or shadows could be a factor but nothing.

It's a mysetery to me why he did it.

A Kurdziel  
#16 Posted : 18 April 2019 12:40:02(UTC)
Rank: Super forum user
A Kurdziel

Ok that particular incident was a lapse in concentration and the injury sustained was not that bad ( I am assuming the finger is still attached to the hand) but the build-up of debris will still happen and he could have another lapse and the next time the injury could be worse so:

  • Could to prevent the build-up of debris
  • Think of some way to stop him coming into coming into with the blade following a lapse of concentration- a hand detection system
  • Why the lapse of concentration – was he doing too much to quickly

There might be other things you can consider. The point is not that you must come up with a solution but you must consider all of the options and decide whether any of them is viable. If the next time the accident is worse and the HSE turn up and see that something similar has happened before they will ask the question “why you did not do anything to improve the procedure” and the only defence you can use  is it was not reasonably practicable to improve the process: saying it was just “human error” will not cut the ice.

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CptBeaky on 18/04/2019(UTC)
Ryan.Donald  
#17 Posted : 18 April 2019 12:51:44(UTC)
Rank: Forum user
Ryan.Donald

I agree with sthe consensus that human error cannot and should not be put down as the cause, human error is the beginning when it comes to incidents and we need to look more closley at the underlyig (dormant) causes to this event - ***practical advise is on its way below not just another academic statement sayiong shall and should***

It states that the machine was to be operated in line with training in the RA - is this enough or do we need to put in place a procedures / process that is known to the user on clearing debris?. Consideration should be given to the influencing factors when doing the RCA, as it is often (90% of the time) that human behaviour is infuenced by something 

Job Planning (incl. process, discussion, familairisation with equipment), time pressures, fatigue (was he using the equipment all day or for a long period of time, is it an automated piece of equipment hat can result in out of loop errors, fixation error, or lack of motivation and attention due to not requiring mental input

The design seems a big one to look at, the person was able to access dangerous areas with the equipment still active - way round this is as I mentioned, create a procedure for the clear out of debris for example

I do love a good Human Factors and human behaviour discussion

MrBrightside  
#18 Posted : 18 April 2019 14:47:04(UTC)
Rank: Forum user
MrBrightside

Originally Posted by: Ryan.Donald Go to Quoted Post

I do love a good Human Factors and human behaviour discussion

Me too! when you look at the ABC model, it would sugest that the IP has probably done this before 'removed the debris by hand' because it's quicker perhaps and without any concequence.

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A Kurdziel on 18/04/2019(UTC)
A Kurdziel  
#19 Posted : 18 April 2019 15:44:52(UTC)
Rank: Super forum user
A Kurdziel

Originally Posted by: MrBrightside Go to Quoted Post
Originally Posted by: Ryan.Donald Go to Quoted Post

I do love a good Human Factors and human behaviour discussion

Me too! when you look at the ABC model, it would sugest that the IP has probably done this before 'removed the debris by hand' because it's quicker perhaps and without any concequence.

We don't use ABC enough in my opinion.

ABC stands for

Antecedents- what led up to the situation?

Behaviour- which is what caused the situation

Consequences- outcomes of that behaviour- this  is the probability of the outcomes and can explain why people think that they can get away with some sort of  behaviours as the reward of that bad behaviour usually outweighs the negative consequences

​​​​​​​
fairlieg  
#20 Posted : 19 April 2019 08:25:42(UTC)
Rank: Forum user
fairlieg

I am not a fan of the way I have seen the ABC model used. Kurt Lewin says you should make it easier for the worker to do what you want them to do. So the BBS people [expletive deleted]ised the consequence part to correct behaviour and we ended up with blame shame retrain or fire becoming overly used because it is easy and emotionally satisfying. The problem being it drives under reporting and we learn less and less about how the work is done and are really surprised when something bad happens because we didn’t know there was a problem because it was hidden out of fear of being blamed shamed retrained or fired.
Dave5705  
#21 Posted : 20 April 2019 07:01:45(UTC)
Rank: Forum user
Dave5705

I would stake my pension that this is not the first time the operator has removed offcuts like this. It could have been for any reason that he did it the first time, push stick out of reach, time constraints, who knows? That's part of the job to find out.

But you must consider that a) it was possible to do it and therefore foreseeable (regardless of mindset at the time) and b) I would also stake my pension that if you do nothing to prevent it, someone will do it again given time. A desire to rush the job to please the boss, rushing to get done and home to the footy match, someone walked off with the push stick, doing it without thinking.

IMHO my take on this is always the same. An employer is in business to make money. It is morally reprehensible to expect any employee to risk his health and safety just to make money for someone else! Human error is usually used to describe something one person said another shouldn't do.

firesafety101  
#22 Posted : 20 April 2019 10:48:04(UTC)
Rank: Super forum user
firesafety101

Isn't every 'accident' caused by human error?

Whether it was as above and the employee probably did something he shouldn's have, or for example a train derailment.  When the investigation gets as far back to the start as possible there will usually be a 'human' element in the cause.

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A Kurdziel on 30/04/2019(UTC)
stevedm  
#23 Posted : 22 April 2019 06:40:14(UTC)
Rank: Super forum user
stevedm

Yep...slips errors or lapses...and these can be in the design of the equipment and or management failings in the 'system'..the difficulty you have is when there is a deliberate act...which in most cases would be a disciplinary...I have investigated three where it was actually attempted suicide...in looking at human factors there are more than just the work areas/ influences to be concerned about...

There is a Kiel centre HSE research report into the offsore industry behaviours post piper alpha that gave a very good model showning that the major of safet/ unsafe behavious start at the other end of the scale with the board etc before you get to employee observations...

Getting back to this - this is entrely foreseeable.  The human error doesn't seem to have been addressed , I am betting when you interview this guy he will have done this a number of times just this time is mis-judged it...

Ryan.Donald  
#24 Posted : 22 April 2019 08:30:24(UTC)
Rank: Forum user
Ryan.Donald

Originally Posted by: firesafety101 Go to Quoted Post

Isn't every 'accident' caused by human error?

From the review of over 250 undesired events at my company (my employer) Human error, or active failure, has been identified as a cause in 80-90% of cases.

I would agree to a pint that if you dig far enough you will "find" a human failure. But it will come to a point that digging so far will have no benefit at all to the investigation, perhaps?. I have said before that if you dig deep enough into an incident you can blame anything on the creation of the earth (side note and a bit of light hearted humour)

I firmly believe that focusing on huam error is important, but not as important as minimising human error and error-likley situations. Manage the error, manage and prevent the incident.

ABC is an interseting topic too

peter gotch  
#25 Posted : 22 April 2019 11:33:35(UTC)
Rank: Super forum user
peter gotch

Meady

What sort of production runs are you talking about? You haven't described the panel saw, but if it's a standard woodworking circular saw with a top guard and nothing much else above the table, then perhaps it's not the most appropriate machine.

.....in other words could this be done with a machine that includes a tunnel guard at the rear (and possibly the front too), so that there is much less reliance on secondary safety devices such as the push stick?

Lots of studies have concluded that human error is associated with over 80% of industrial accidents. Other studies have concluded that unsafe conditions are ALSO associated with a similar proportion of such accidents. Fix the unsafe conditions, the unsafe acts become less important!

Beware the studies that have insufficient data to come to statistically significant conclusions. Even if those studies often come to the same conclusions as regards human factors, whilst often ignoring the unsafe conditions, sometimes because they are based on some Behavioural Safety campaign and don't actually want to find a solution other than unsafe behaviour.

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Dave5705 on 25/04/2019(UTC)
Ryan.Donald  
#26 Posted : 22 April 2019 11:45:24(UTC)
Rank: Forum user
Ryan.Donald

Originally Posted by: peter gotch Go to Quoted Post

Fix the unsafe conditions, the unsafe acts become less important!

I like that quote Peter- its a case of managing the unsafe influencors and avoid putting people in error likley situations

Edited by user 22 April 2019 11:46:57(UTC)  | Reason: referenced wrong user

chris42  
#27 Posted : 25 April 2019 12:52:48(UTC)
Rank: Super forum user
chris42

This is interesting. The way the OP describes the work being done is the way these items of equipment are intended to be operated. However, this does normally mean there is a wedge-shaped gap under the top guard, which will be the height of the work being cut at the back, tapering down to nothing at the front, leaving that portion of the blade exposed at the back. However, that is how the manufacturer intends its use.

So even if there may be a better machine as Peter rightly mentions, there are a lot of these table circular saws about, so is their design inherently flawed? And should not be on sale?

Chris

CptBeaky  
#28 Posted : 25 April 2019 13:09:15(UTC)
Rank: Forum user
CptBeaky

As you know, all machinery needs to be inspected for safety by the purchaser. We cannot rely on CE marks etc. The manufacturer only has meet regualtions, this does not ensure a safe machine when it is placed into a different work area. I have had several machines purchased that I have insisted on modifications being made before it was deemed safe to operate. A classic example would be when a machine is put into a sound proof enclosure to reduce noise. Should the manufactuers just make the machines quieter? Or should they supply them with soound booths?

It does seem to be an inherant design flaw, but without knowing the specifications they are being built to it is hard to say whether it could be changed by the manufacturer. It might be that it reduces the dimensions of workable pieces if it is fixed, thus reducing the sales potential.

Dave5705  
#29 Posted : 25 April 2019 13:51:21(UTC)
Rank: Forum user
Dave5705

After a hard nights rain, I left the house this morning and stepped in a puddle on my drive. It hasn't rained for several days, but I knew the puddle was there when it rains, it's always there when it rains. I was annoyed because I got wet feet. Why did I step in the puddle? Because it was there. 

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CptBeaky on 25/04/2019(UTC)
ttxela  
#30 Posted : 25 April 2019 15:02:50(UTC)
Rank: Forum user
ttxela

Originally Posted by: chris42 Go to Quoted Post

This is interesting. The way the OP describes the work being done is the way these items of equipment are intended to be operated. However, this does normally mean there is a wedge-shaped gap under the top guard, which will be the height of the work being cut at the back, tapering down to nothing at the front, leaving that portion of the blade exposed at the back. However, that is how the manufacturer intends its use.

So even if there may be a better machine as Peter rightly mentions, there are a lot of these table circular saws about, so is their design inherently flawed? And should not be on sale?

Chris

I suspect the reason there are a lot of this type of table saws around is because they are versatile and flexible, generally unless you are a one product facility you need your saw to be able to do all sorts of things. Anything you can feed a peice of wood into to be cut you are going to be able to feed your hand into if you are determined enough.

Occasionally inexplicable things do happen, years ago we had an incident where a senior sceintist removed all the guards from a UV lamp and stared into it for a while, it involved temporary loss of sight so was reportable.

Everything was in place to allow the lamp to be used safely all of which he carefully removed to allow the accident to happen, he wasn't stressed, tired or under any pressures and was fully trained in its use. Afterwards he even described thinking to himself as he did it that it was a silly thing to be doing...... He was a perfectly sensible intelligent and responsible chap both before the incident and after. He had been using the equipment for many years and continued to do so.

The human brain/mind is a very strange thing and occasionally there just is no explanation.

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A Kurdziel on 25/04/2019(UTC), chris42 on 25/04/2019(UTC)
chris42  
#31 Posted : 25 April 2019 15:23:07(UTC)
Rank: Super forum user
chris42

I was just stating how it is designed and supplied any modification to guarding yourself, could / would become an issue. I’m not saying other things can not be put around the machine, even light guards for instance. However, what was described by the OP is what the Manufacturer intended. It is nice to think even the smallest manufacturing units when buying equipment will be able to get manufactures to change their designs, but I suspect most do not have that much clout unless buying bespoke equipment.

Quite a bit of equipment is sold with exposed cutting faces ie a bench grinder, hand held circular saw, reciprocating saws.

I was not disagreeing with the concept that people are not machines and exposed parts if distracted are a danger. Guarding should protect the careless or inattentive worker as well as those that are careful. However, if you fully guard a machine’s cutting edges you end up making it unusable as per the old argument from Summer v Frost (yes, I know Factories act has gone). But the argument is the same.

MaxPayne  
#32 Posted : 30 April 2019 11:47:42(UTC)
Rank: Super forum user
MaxPayne

cognitive dissonance
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