HSE ALERT

Bulletin # 72014 Completed By Gaute Fossaa

Incident Date: 11-05-2020 Approved By Derek Dixon
Incident Classification
☒Injury/Illness ☐Environmental ☐Vehicle Accident ☐Property/Equipment Damage ☐Near Hit/ Miss
☐Security: Please Specify ( __________________ ) ☐Other: Please Specify ( __________________)

Preliminary Details of Incident

An employee suffered a fracture to their right index finger when it struck the rotating chuck of a CNC lathe. After a
machining process, using an Okuma CNC lathe, the machine operator used abrasive paper (Emery cloth) to remove a
sharp edge on the machined component.

What Went Wrong?

With the chuck and component rotating at
approximately 300-400 RPM, the injured person
(IP) opened the door/guard and, holding abrasive
paper with their right hand, reached into the
machining area and applied the abrasive paper to
the sharp edge of the component using firm
pressure. During this this action, the IP’s hand
slipped and stuck the rotating chuck.

Immediate Cause(s)-
Unsafe condition – inadequate protective systems. The guard/door was not fitted with an interlock.
Unsafe act – shortcut. The sharp edge could have been removed using the machine tooling/programming.

Immediate Actions-
Toolbox talk held with workforce to discuss the incident and safer machine use.
Internal training in safe use of working equipment carried out.
Machinery manufacturer contacted to install Interlock.
Risk assessment reviewed.

Lessons Learned-
If the guard had been fitted with an interlock safety
device, it would have prevented access to dangerous
parts during operation of the machine by locking the
guard in place or stopping the machine if the guard is
opened.

Reminder:
Defeating/Overriding machine interlocks can
result in unnecessary exposure to hazards and
can be deemed as gross misconduct.

HSMSF-050.005 Rev. 01 Form Revision Date: 10-Dec-2019 Page 1