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

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.

Im not sure what you are asking!

You know its reportable so whats the question?

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.

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…

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?

Hi Meady,

Did he give a reason for his actions?

Regards

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.

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

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.

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...

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.

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

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. 

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.