Learning bulletin: Coppermills – Falling object What happened? The injured person was working in a Slow Sand Filter outlet chamber carrying out planned maintenance on the outlet valve gearbox – following a recent issue with Water Quality all SSF valve sets must be serviced when the bed is out for cleaning. As the drive shaft was lifted off the gearbox a coupling came apart and the upper section of the shaft fell from height, making contact with the injured person’s head. He sustained a cut requiring 8 stitches and was off work for 6 days. Why did it really happen? A taper pin was missing from one end of the coupling on the drive shaft. Prior to starting work, the drive shaft couplings were not checked because the valve set had been operating correctly – if this was a reactive job, checks would have been more thorough. The injured person’s hard hat fell off as he bent forward to lower the shaft as there was no chin strap fitted. What can I do differently? Ensure a thorough SHE5 risk assessment is undertaken for all maintenance tasks, however routine. When working on valves, ensure all couplings are secure before dismantling equipment. Always leave plant and equipment in a safe condition after completing works. Use a chin strap on hard hats for tasks where there is a risk of the hat coming off – if the hard hat had remained in place the injury could have been avoided.

Learning bulletin – Hampton Telehandler Incident What Happened? Why did it really happen Poor decision making by the telehandler Operative. He felt it would save time to move the mobile scaffold whilst still erected . Mobile Scaffold had not been dismantled after the task was completed. Risk Assessment , Method Statement and Lifting Plan made no reference to movement of equipment from one location to the next. Lack of adequate supervision. Site supervisor had already left site for the day. Human Failing – Deliberate violation, Operator knowingly taking shortcuts, or failing to follow procedures, to save time or effort. At Hampton WTW one of our contractors was witnessed driving a telehandler across the empty bed of a slow sand filter, with a mobile tower scaffold resting on the forks. While attempting to drive up the ramp the scaffold became dislodged and fell. The driver parked the vehicle on the ramp and attempted to reattach the scaffold to the forks, at which point the vehicle rolled back down the ramp and into the bed. No one was injured as a result of this action. What can I do differently? Improve risk perception, promote understanding of “whys” and consequences. Ensure effective supervision at all times. Eliminate reasons to cut corners; ie. providing sufficient time to complete tasks. Improve our safety Culture; by encouraging the reporting of safety observations, Use the Blue card to challenge and stop unsafe behaviours. Gordon Rickards Learning from Incidents