Description:

1. Accidents – October 2009 Recordable (Ref. 2009162)Maintenance & FabricationsOctober 6, 2009 Location: Bldg. 968 Injury :Fractured finger Rails shown in the lowered pinch point position Piston sits inside the green rails Description: The assigned CAD electrician was repairing a pipe bender and was in the process of removing its hydraulic holding piston when the cylinder and side supports slipped and pinched his left thumb between the assembly and bottom rail. The cylinder‘s seal had failed, leaking hydraulic fluid, therefore the cylinder/rail assembly was slippery. Later it was determined that his finger was fractured. The workers (2) were using the pipe bender operator manual for the repair as they had never repaired this bender before. The manual did not provide any safety caution for this slippery condition. • Causes: • The cylinder slipped out of the hand of the worker and pinched his finger against the rail. The cylinder was slippery due to hydraulic oil that had leaked over it from a failed seal. This repair is performed infrequently and the worker sort additional information from the operator’s manual, however the manual was insufficient to support this task. Repairs should have been performed by the Fabrication Shop, but electricians were trying to reduce downtime for this bender to support RHIC which was down for maintenance. The bender was needed to continue work and there was a sense of urgency to the repair, which resulted in an error trap due. • Corrective Actions: • The electricians have been informed that non electrical machine failures are to be sent to the Machine Tool Rebuilder in the Fabrication shop for repair. Action complete. • The facts of this incident were shared with the Machine Tool Rebuilder as a lessons learned. Action complete. • All workers were reminded of the errors that can and do occur when work loads are high and that their safety must take presentence of the work. Action complete.