1. Investigate the accident ?[10 Points] a. Develop a 5-Whys Tree and determine
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Question
1. Investigate the accident ?[10 Points]
a. Develop a 5-Whys Tree and determine the Root Cause (5 Points)
b. Develop a JSHA (5 Points)
Case Study #1-Amputation in Meat Grinder A 15-year-old part-time worker (the victim) at a retail grocery store suffered amputation of the right arm as a result of being caught by the auger of a meat grinder while he was reassembling it The victim, working after school, had completed washing and cleaning the disassembled parts of the grinder and was reassembling it without de-energizing and locking out the machine's power supply (See Photos Below). He inserted the auger into the grinder's housing and reached through the feed-throat with his right hand to guide it into engagement. As he did so, he bumped against the unprotected on/off lever switch mounted about waist high on the machine's side. The grinder started and the auger pulled his hand and arm into the housing. He turned the machine off, pulled his arm from the grinder housing and ran toward the front of the store. The store manager applied pressure to his bleeding arm while a coworker called 911. The victim was transported to a local hospital. His right arm had been amputated just below the elbow. A magnetic safety switch mounted on top of the motor starter was designed to prevent operation when the Removable Tub was taken off. The safety switch had not worked for over 16 years and employees were not aware that the safety switch existed. (Source: http://www.cdc.gov/niosh/face/In- house/ful1200013.html) Removable Tu On Off Switch Grinder Housing Magnetic Safety Switch onioft Switch Motor/Transmission Cabinet Grinder Housing Flexible CordExplanation / Answer
1. Investigate accident
A. The worker is 15 years old minor and it is wrong for the manager of the store to use minors to work in hazardous situations without giving proper training. The Child labor laws are not followed by owner.
B. Looking at the pictures it is notworthy that the power cord is placed under the table and hence the ON OFF switch is not accessible easily. It is dangerous situation as the person working on the grinder might not be aware that the Power is turned On or OFF.
C. A safety switch is as good as Not having one as it was not functional. The responsibility of the maintenance team is to make sure all safety devices are in working condition to avoid accidents. A system of proper preventive maintenance check ups can identify the issues which was not done.
D. A visual aid to assist the machine operator is missing. The Standard Operating Procedure to disassemble the machine and cleaning it is a must for all power tools. Lack of proper work instructions also is a serious issue on the part of the operations manager.
E.Many other crucial factors are not clear. Only after on the spot investigation and analysis of the various statements as provided by the owner, operations team, the victim are necessary to understand why exactly the accident happened. It is also possible that the victim was responsible for the accident.
1a. Five Why tree analysis
Accident ( Amputation of hand in grinder)
WHY
Augur turned on while cleaning
WHY
Power not turned OFF
WHY
Victim not aware about turning Power OFF
WHY
No proper training provided
WHY
Lack of training system
1b. JSHA ( Job Safety and Hazard Analysis )
Attached table
JSHA Job Steps Safety and Hazard Preventive Measures Turn the Machine power OFF Power is not disconnected Power Switch is visible and easily accessible placed near the machine Disassemble the parts for cleaning Power chord is attached to main supply OR Machine switch is not turned OFF Clear work instructions/ training to detach the power chord before any disassembly and turn Machine switch to OFF condition Cleaning of Augur ( Moving parts) using manual procedure Worker body could get entrapped in the moving machine parts Safety switch/ Red Lamp / Alarms to warn worker about possible danger Wrong process used by new worker to clean the eqippment Machine sharp components and the worker is not safe Under the supervision of Senior person / Trained labor to perform risky operationsRelated Questions
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