Safety Alert

November 2022 ⏐ Safety Alert No. 1

LOST TIME INJURY (LTI) CAUSED BY SNAPPED BOLT

STRUCK TEC PERSONNEL’S FOOT
BACKGROUND

On September 24, 2022 at around 8:15 PM, while conducting of inspection at PAG3 Vibrating Screen
Bravo, the right foot of TEC Mechanical Technician (inspector) was struck by a snapped bolt that flew
off from the rotating flywheel weights assembly of the Drive End (DE) side.

The flywheel and additional weights assembly rotates at 850 rpm giving significant force to the
snapped bolt to take off. The technician suffered lacerated wound and fractured bone injury to the
big toe (right foot) after the bolt went through the safety shoes (soft portion, no steel). He
immediately went to the clinic for first aid treatment. He was later brought to a nearby hospital
where he was given proper medical treatment and an advice of 6-8 weeks healing period.

ILLUSTRATIONS

Illustration A. Point of contact of Illustration B. Snapped bolt

the snapped bolt to the TEC involved in the incident that struck
Mechanical Technician the TEC personnel
 Illustration C. Location of the bolt in PAG3 Illustration D. Reenactment of the Accident
Vibrating Screen Bravo before it snapped. (Inspection at PAG3 Vibrating Screen Bravo)

ROOT CAUSE
Unbalanced bolt torque or looseness that eventually resulted to cyclic fatigue. No bolt or thread locking
mechanism to prevent loosening due to vibration or stress.

CONTRIBUTING AND CAUSAL FACTORS

Inadequate engineering and administrative controls
● The existing machine guard covers only the upper portion of the rotating flywheel. The lower portion was
unprotected - this is where the sheared bolt exited on the incident.
● Current Maintenance Instruction does not include the routine inspection of bolts tightness and torque.

LESSON LEARNED
● Machine guarding is critical for all rotating equipment due to its exposed parts
● Proper preventive maintenance plan is necessary to ensure equipment is in good running condition.

CORRECTIVE ACTIONS
System Design
● Fabrication and installation of machine guard to cover all areas with potential flying object hazards, and
accidental access to rotating equipment parts of the vibrating screen.
● Provision of engineering study modifying counterweight block, and its bolts including applicable locking
mechanism.

Administrative
● Restriction of access or entry to Pag3 Vibrating Screen Area while equipment is in operation.
● Revision of maintenance instruction by establishing a routine bolts torque check every 3 months.