Lessons learned: Risk assessments should always reflect the real world of work
IMCA draws lessons learned from an incident where steel plates suddenly toppled over to the side trapping a worker’s left hand and wrist between a frame and an emergency stop pedestal.
The incident
A worker was using their left hand to hold a number of steel plates in a vertical (balanced) position. One of the plates suddenly toppled over to the side trapping their left hand and wrist between a frame and an emergency stop pedestal. The worker suffered crush injuries resulting in multiple fractures to the hand, wrist and fingers requiring surgery. Also, the falling plate caught the worker on the left side, causing a superficial laceration to the abdomen.
IMCA’s member considered that a potential consequence could have been permanent disability to the hand, wrist or fingers and the potential for a more severe abdominal injury.
What were the circumstances?
- The steel plates were being stored in a temporary arrangement outside the designated steel rack:
- There had been no supervisory oversight of the decision to store the plates in this temporary way;
- There was limited space in which to work.
- Sea fastenings had been removed during voyage, increasing risk of plate movement.
- Work as planned, work as done: the risk assessment did not reflect real task conditions.
- The task had been done this way without any problems in the past. Perception of risk could have been better:
- The workers just got right on with the task and did not pause for a last minute risk assessment;
- No manual handling aids were used.
Lessons learned
- Do our risk assessments always reflect the real world of work – i.e. work as DONE?
- Do risk assessments take into account “temporary” changes that sometimes become effectively permanent?
- Can we design and arrange storage to prevent this kind of thing happening? Have a look at the way materials are stored, particularly when “temporary” storage may be involved.
- Stop and think – take time out to think things through!
The circumstances show how local conditions, past experience and system constraints shaped work as done, rather than a conscious disregard for safety.
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