WSHAC WSHAC WSHAC WSHAC Workplace Safety & Health Advisory Committee

2006 WSHAC
Case Studies
Case Studies
for the
for the
TRANSPORT AND
LOGISTICS SECTOR
RELATED ACCIDENTS
TRANSPORT AND
LOGISTICS SECTOR
RELATED ACCIDENTS
Prepared on 4 December 2006
Please note that all cases are shared for learning purposes
only and in no way implies any liabilities on any parties.
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2006 WSHAC
Case Study 4
Unguarded Winch Causing
Permanent Injury
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2006 WSHAC
Brief Description of Accident
Brief Description of Accident
Date: April 2005
Work process:
Replacing main hoist wire rope of a transtainer cranes spreader
Casualty: One permanent injury
Transtainer
Cranes
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2006 WSHAC
Synopsis of Accident
Synopsis of Accident
5 workers were replacing the main hoist wire rope of a
transtainer cranes spreader.
One of them (the injured) operated the electrical winch to
lift up the new main hoist wire rope to the trolley platform.
Winch drum
Electrical
winch
Winch wire
rope
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2006 WSHAC
Synopsis of Accident
Synopsis of Accident
The injured had used his left hand to operate the control panel
of the winch while his right hand held the winch wire rope.
Suddenly, he felt a jerk on the winch wire rope and he
immediately stopped the winch.
Winch
control panel
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2006 WSHAC
Synopsis of Accident
Synopsis of Accident
However, his right hand was pulled to the winch drum
and his fingers were caught in-between the winch wire
rope and the winch drum.
He released the rope to release his injured fingers but
part of his middle, ring, and little fingers were later
amputated by the doctor.
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2006 WSHAC
Observation and Findings
Observation and Findings
The electrical winch was examined prior to the operation
and was operated by an approved person.
The winch was not covered with a safety guard.
The injured worker was positioned near the winch to
operate the control panel and his right hand was about
20cm from the winch drum.
The injured was required to react fast to stop the winch
or remove his hand should the needs arise.
There were two previous occasions where the injured
had almost caught his hand in the winch drum.
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2006 WSHAC
Root Cause Analysis
Root Cause Analysis
1) Inadequate hazard analysis
2) Inadequate safe work practice
Failure of SMS
Inadequate identification and
evaluation of loss exposure on
the winch
Basic cause
No safety guard and improper
position for task
Immediate cause
Caught in between the winch
drum and the winch wire rope
Type of contact
Amputation of right distal middle,
ring and little fingers
Evaluation of loss
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2006 WSHAC
Corrective Measures
Corrective Measures
Install remote control to replace the control panel in
controlling the electrical winch and all workers briefed to
position at a safe distance from the winch during operation
Test and thoroughly examine winch by an approved person
Install safety
guard on the winch
WSHAC WSHAC WSHAC WSHAC Workplace Safety & Health Advisory Committee
2006 WSHAC
THE END
THE END