This document describes a workplace injury that occurred at GE involving an employee cutting plastic using a retractable knife. The employee's left forefinger was cut when the knife slipped sharply while performing the cutting motion. Root causes identified include an inadequate tool for the finishing activity, gloves that did not provide sufficient protection from cuts, and unsafe hand positioning during the activity. Corrective actions will be identified and assigned to a responsible person with a target closure date. Lessons learned and key error enablers that allowed the incident are also noted.
This document describes a workplace injury that occurred at GE involving an employee cutting plastic using a retractable knife. The employee's left forefinger was cut when the knife slipped sharply while performing the cutting motion. Root causes identified include an inadequate tool for the finishing activity, gloves that did not provide sufficient protection from cuts, and unsafe hand positioning during the activity. Corrective actions will be identified and assigned to a responsible person with a target closure date. Lessons learned and key error enablers that allowed the incident are also noted.
This document describes a workplace injury that occurred at GE involving an employee cutting plastic using a retractable knife. The employee's left forefinger was cut when the knife slipped sharply while performing the cutting motion. Root causes identified include an inadequate tool for the finishing activity, gloves that did not provide sufficient protection from cuts, and unsafe hand positioning during the activity. Corrective actions will be identified and assigned to a responsible person with a target closure date. Lessons learned and key error enablers that allowed the incident are also noted.
This document describes a workplace injury that occurred at GE involving an employee cutting plastic using a retractable knife. The employee's left forefinger was cut when the knife slipped sharply while performing the cutting motion. Root causes identified include an inadequate tool for the finishing activity, gloves that did not provide sufficient protection from cuts, and unsafe hand positioning during the activity. Corrective actions will be identified and assigned to a responsible person with a target closure date. Lessons learned and key error enablers that allowed the incident are also noted.
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Site Name / Location : Gensuite Case Number:
Date and Time:
Injury Type/Body Part : Employee Years of GE Experience: Recordability Rationale: 5 days away from work DAFW: YES Management System Failure: No Incident Location: GE
Description:
Shift Overtime work - No Normal or unusual task - Normal Personnel involved Fbio dos Santos INSERT PHOTO: Equipment and process involved Stylet Starret Add additional photos on Environmental conditions Not aplicable Accident description must be in sequence from beginning to end of the event second page if needed. Employee was cutting plastic trunk using retractable knife when performing the cutting motion, the retractable knife slipped sharply, reaching its forefinger of his left hand, which was positioned above the piece, holding it. Root Causes (include Causal Analysis Results): Lessons Learned
Inadequate tool for the finishing activity; Lessons learned 1
Gloves without suficient protection for the risk of cuttings with retractable knife; Unsafety hand positioning during the activity; Lessons learned 2 HOP Considerations: Key Local Factors (Error Enablers) / Active Errors (Triggers) / Risk-Important Steps Latent System Weaknesses (LSW)
Corrective Action (including HOP Error Enablers & LSW actons) Responsible Person ATS ID Target/Closure Date Strength of Defenses Matrix Personal Type Engineered Admin Oversight Cultural Defenses Defenses Defenses Protective Defenses Purpose Equipment Eliminate Ex: eliminate need for permit confined space entry, substitute les hazardous Ex: SRA with Critical Steps. No single error vulnerability at critical Ex: Supervisor verify daily checklist inspection to confirm critical controls Not Applicable Ex: effective employee EXPECTATION to stop unsafe work; consistent (substitute) Strength of Defenses material, task redesign to steps operating correctly management style eliminate hazard reinforcing H&S
Prevent Matrix required for all Ex: machine guard, local Ex: limit on maximum Ex: Permit to Work before Not Applicable Ex: Chronic unease and exhaust ventilation, or exposure time to hazard, proceed with high risk task questioning attitude interlock equipment-specific LOTO emphasized by leadership procedure, or permit to and employees work, training on SRA
Catch RECORDABLE and A / B Ex: process over-pressure or high temperature sensors with Ex: peer check at critical step Ex: supervisor approval prior to high risk task Ex: Faceshield for splash protection, cut resistant Ex: stop when unsure
cases. emergency shutdown gloves procedures
Detect Ex: continuous air monitor to
hazardous gas Ex: pre-job checklist inspection Ex: supervisor audits to verify use of established procedures. Add to Ex: Personal dosimeter for ionizing radiation Ex: active use of Concern Reports
supervisor scorecard.
Mitigate Ex: blast barriers, noise baffles Ex: training on response to
unexpected conditions, CSE emergency rescue Ex: supervisory verification that only necessary and qualified personnel Ex: Vibration attenuation gloves Ex: Value system, priorities
arrangement allowed where HRO to be
performed
Purpose what you want to achieve in terms of hazard defense and error management Type how you want to achieve it; determines reliability of defenses. All defenses have value but up / left in matrix are stronger/more reliable Describe your selected corrective actions in the appropriate cells. Adapted from Muschara Error Management Consulting, LLC IT IS NOT NECESSARY to have an entry in every cell 2 Strength of Defenses Matrix Personal Type Engineered Admin Oversight Cultural Defenses Defenses Protective Defenses Purpose Defenses Equipment Eliminate Not Applicable
(substitute) Strength of Defenses Prevent Matrix required for all Not Applicable
Catch RECORDABLE and A / B cases. Detect
Mitigate
Purpose what you want to achieve in terms of hazard defense and error management Type how you want to achieve it; determines reliability of defenses. All defenses have value but up / left in matrix are stronger/more reliable Describe your selected corrective actions in the appropriate cells. IT IS NOT NECESSARY to have an entry in every cell 3 Root Cause Contributing Factors Required for Administrative Contributors Missed Critical Steps Ergo Contributors LEVEL A / B
RCA Tool must be used
for A / B cases. Other Resulting
RCA tools are injury or
illness
permitted in addition to fishbone.
Machine Environmental Personal Contributors
Contributors (Must Include Active or Latent Errors)
HOP: Highlight Active Errors & LSW in Purple
4 GE Energy Management Guidance Establish the facts, trace the root causes, Eliminate insignificant causes, Identify realistic actions
Accident Description: Root Causes:
(A detailed chronological sequence of events) Questions you should ask yourself Why did this event happen? Accident must be precisely described, including: What happened before, during & after What was the EE doing there? Date and time Does this task/process need to take place? Location Was pre use inspection done? Shift Is this the best way to do it? Have we looked at other ways? (different Overtime work tool, lift assist, process flow redesign, job rotation) Was the right tool used for the job? Normal or unusual task Is maintenance(PM) done and sufficient? Personnel involved Was training given and sufficient? Equipment and process involved Was this injury reported on time? If not why? Environmental conditions Has this happened before? What did the EE have to say during the investigation? Accident description must be in sequence from beginning to Is this a quality or sourcing issue? end of the event Was EE in a rush? If so why? Is this an ergo related injury or illness?
HOP Guidance: Refer to slides 6-7 for HOP Guidance. Corrective action Each root cause / contributing factor must be followed by its own corrective action, detailed on Slide 1 and uploaded in ATS.
The corrective actions must be reflected in the JSA/SRA update if applicable.
If ergo related, the ergo team and the injured employee must be involved in the corrective action. If there are any similar applications where these corrective actions can be applied, add to Slide 1 under Corrective Actions. *** Think of Engineered solutions, training ,administrative solutions, PPE.. In this order*** 5 Applying HOP to Incident Review HOP Incident Review Questions Questions for Incident Investigations 1. Were there critical steps identified in the procedures / processes?
2. Did the employee recognize those steps and take appropriate actions? Did the employees understand and/or acknowledge the critical steps? If yes, what actions did he/she take?
3. Were there risk important actions identified in the procedures / processes? Change procedure to work instruction or have both. Some people call them procedures some work instructions.
4. Did the employee recognize those steps and take appropriate actions? Did the employee understand the steps and mitigate any/all risks during the task?
5. Describe the multiple levels of defense (controls, barriers, safeguards) in place at critical & risk important steps in the process.
6. Were there conflicting goals, directives, procedures from the Supervisor, contractor, work leader, EHS, etc.?
7. Put yourself in the person who made the errors place. Why did what he/she chose to do make sense to them at the time and under the existing circumstances? (Do everything possible to eliminate hindsight bias). a. How did the site world look to them? b. How did the situation unfold around them? c. What cues did they receive and when (i.e. see, hear, touch, or feel)? d. What were they paying attention to? e. What factors / error traps influenced their decision making? f. Were they going with the flow of what was happening around them? 6 Applying HOP to Incident Review HOP Incident Review Questions Employee Questionnaire / Discussion Please rank the following factors on a scale of 1 to 10 with 10 being the most impactful and 1 the least, in playing a part in your injury.
1. The lack/shortage of supervision/direction ( 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 )
