The Risk Management Tool Box Blog

Controlling for Human Error During Maintenance

Graham Marshall - Friday, April 26, 2013
Maintaining equipment is one of the most critical risk control measures available to any work place.

And  a lack of maintenance, or errors during maintenance activities can create underlying triggers which may contribute to accidental hazard release later on. 

For example, when servicing an elevating work platform, a maintenance technician could forget to install the appropriate counter-balance water within the tyres of the EWP. 

This error may go undetected until the EWP is raised into position for use, with potentially disastrous consequences for the operator if the EWP tips over.

There are a number of solutions that can eliminate or minimize the potential for maintenance error. 

For example, the development of appropriate maintenance procedures; alongside a program to ensure that the actual procedures are read and applied by those responsible for the work can go along way to minimizing risk.

Adequate personnel resourcing is also important to ensure that there are enough people to undertake maintenance work.

The following additional strategies can also assist in minimizing and mitigating maintenance error:

   Allow enough time for maintenance task completion;

   Scheduling should allow for effective diagnosis and problem-solving, and reduce the likelihood of corner-cutting or memory lapses;

   Eliminate mid-task interruptions of maintenance technicians. Mid-task interruptions can cause maintenance technicians to forget their location in the Procedure, and consequently to miss critical steps;

   Avoid ‘bumping’ maintenance personnel in favour of production-related project personnel;

   Increased maintenance backlog is likely to lead to real or perceived time pressure, increasing the likelihood of error;

   Further, this practice may lead to a workforce perception of an overriding production priority, which may then negatively influence workforce risk management behaviour;

   Develop a quality assurance process within each Procedure to be implemented for all maintenance tasks;

   These processes should allow for a detailed review and audit of all work completed within the maintenance task, including steps completed, equipment used/installed, and checks conducted by the original technician. At Risk Tool Box, we always include an audit protocol for each Procedure we develop;

   Assign such quality assurance tasks to more experienced technicians, and prioritize these tasks over others; and

   Allow extra time for the Audit program to promote thorough and detailed procedure review.

Tips to Prevent Lower-back Injury

Graham Marshall - Wednesday, March 20, 2013

Following the common cold, lower back pain resulting from poor manual handling technique is the most common cause of lost work time.  In the USA alone, back pain results in $126 billion in compensation pay-outs and medical expenses each year.

Tips to prevent back injury at work or at home include:

+  Practice good posture and try to stay physically-fit;

+   Use mechanical lifting aides whenever possible;

+   Before manually lifting an object, apply "Think 6, Look 6" and size-up the task;

+   If an object is too big or too heavy to handle on your own, ask someone to help;

+   When lifting, stand close to the object, bend your knees and keep your back straight as possible;

+   Try to lift objects using he muscles in your legs and arms working together;

+   Hold objects close to your body when carrying them;

+   Never twist your body from the waist when handling a load;

+   If you need to turn, do so my moving your feet; and

+   Be careful when setting a load down.

Workplace Ergonomics

Graham Marshall - Tuesday, March 19, 2013

The objective of ergonomics is to achieve the maximum-possible efficiency between the human body and the environment in which activity takes place.

It's about fitting the environment to the person in order to reduce the chance of injury and maximize the benefits available (e.g., time, production, effort, etc).

Here are some tips for ensuring the ergonomic aspects of the workplace are considered:

+   Modify the environment to suite the people working there;

+   Minimize the need for repeated motions, forceful exertion, prolonged bending, and exposure to vibration.

+   Use mechanical methods to lift or move objects rather than human labour;

+   Provide "comfort" mats for people required to stand for long periods;

+   Alternative and schedule harder tasks with easier ones;

+   Offer and enforce regular rest breaks; and

+   Maintain an appropriate workplace temperature and lighting conditions; and

+   Minimize noise.

Control Pinch-point Risk

Graham Marshall - Wednesday, November 07, 2012

Pinch-point incidents are common across workshops, in the field, and in office environments. 

So workers should always take care, even if an environment seems safe and hazard-free.

Typical examples of pinch-point incidents include situations where people trap their fingers in door-jams, in desk draws, in car doors, or inside equipment.

Pinch-points are produced when either two moving parts come together (e.g., when rotating gear cogs turn) or when a single moving part comes in close proximity to something solid (e.g., when a moving door slams against a door frame).

In either case, it is the kinetic energy involved with the movement potential of the object in motion that causes harm when a person gets a body part in the way!  Ouch.

Pinch-points most usually impact onto fingers or hands, but any part of the body can be impacted.

This can be particularly dangerous wherever the space between the moving parts is just sufficient to allow a larger body part to be present when the moving parts come together.

The injury resulting from contact with kinetic energy in a pinch-point can be as minor as a small cut to as severe as having your head pulled off! 

So take care around all pinch points.

The common causes of pinch-point incidents include:

●  Putting a body part in the "line of fire" of the energy source;

●  Not paying attention to hand or finger placement;

●  Wearing loose clothing, long hair or jewelry which can be caught in rotating equipment;

●  Failure to use a machine's guard mechanism;

●  Poor hand placement when lifting or moving materials during manual handling;

●  Improper use of a tool; and

●  Failing to de-energize and isolate a machine before performing some kind of inspection or maintenance task.

Because of the risk associated with pinch-points, make sure you use the following controls to stay safe:

●  Always use the Think 6, Look 6 hazard management process to identify and control pinch points in every task;

●  Use handles when opening drawers;

●  Keep fingers out of "line of fire";

●  Verify that guards are in place and used on equipment that requires guarding;

●  For some jobs, ensure you're wearing gloves (of the correct type);

●  Identify pinch-point risks and the correct controls for these on your JSA;

●  Apply lock-out, tag-out procedure for energy isolation before working on the internals of any machine; and

●  Never remove equipment safety devices.

Prevent on the job eye injury

Graham Marshall - Thursday, November 01, 2012

There are about 2.4 million eye injuries to people in the USA each year.  35 per cent result from a foreign body entering the eye.  25 per cent result from impacts.  And 15 per cent result from burn injuries to the eye.

About 10 per cent of eye injuries will result in permanent loss of vision to the affected eye.  That's over 240,000 serious eye injuries each year in the USA alone.

Virtually all of the harm caused by incidents to the eyes can be prevented or reduced if workers are using the Think 6, Look 6 process and the correct eye protection.

So what can you do?

Firstly, always use the Risk Tool Box' Think 6, Look 6 hazard management process to identify and evaluate the hazards you face which could lead to eye damage.

●  Identify the hazards and triggers in the task to be performed;

●  If necessary, develop a JSA with appropriate controls for the hazards and triggers; and

●  Attempt to eliminate the hazard wherever possible.

Secondly, aim to create a safe working environment:

●  Make sure you're trained to do the job;

●  Use only the proper tools and following the correct procedure for tool use;

●  Keep non-essential people well away from the work zone; and

●  Inspect your tools and other associated equipment before each use.

Thirdly, wear the appropriate personal protective equipment (PPE):

●  Wear safety glasses to ANSI Z87.1 standard;

●  Use additional full face shielding for jobs which are more prone to create flying debris or spray of substances;

●  Use welding hoods with properly shaded lenses when undertaking or assisting with hot work; and

●  Inspect and clean your eye-wear PPE before each use.

CSB Announces Findings into DuPont Fatal Accident

Graham Marshall - Monday, May 07, 2012

The U.S. Chemical Safety Board (CSB) has determined that an explosion at a DuPont facility in the USA that killed one contract welder and injured his Foreman in 2010, was caused by the ignition of flammable vinyl fluoride inside a large process tank, a hazard which had been overlooked.

The accident occurred at the DuPont chemical plant in Tonawanda. 

The facility produces polymers and surface materials for countertops.

The process for making the polymers involves transferring polyvinyl fluoride (PVF) slurry from a reactor through a flash tank and then into three storage tanks.  The tanks were also inter-connected by an overflow line. 

Days before the incident the process had been shut down for tank maintenance.
The tank fill lines were correctly locked out for safety.

Tanks 2 and 3 were repaired and the process restarted, but work on tank 1 was delayed due to a lack of parts.

Although tank 1 remained locked out from the main process, the overflow line remained open which connected tank 1 to tanks 2 and 3.

The CSB found DuPont erroneously had determined that any vinyl fluoride vapor that might enter the tanks would remain below flammable limits.

The CSB determined that flammable vinyl fluoride flowed through the overflow line into tank 1 and accumulated to explosive concentrations.

Although DuPont personnel monitored the atmosphere above the tank prior to authorizing hot work to restart once parts became available, no monitoring was done inside the tank to see if any flammable vapor existed there.

The CSB investigation found the hot work ignited the vapor as a result of the increased temperature of the metal tank, sparks falling into the tank, or vapor wafting from the tank into the hot work area.

The explosion blew most of the top off the tank.

The welder died instantly from blunt force trauma, and the foreman received first-degree burns and minor injuries.

CSB Team Lead Johnnie Banks said, “Our investigation found that DuPont’s process hazard analysis incorrectly assumed that vinyl fluoride in the process could not reach flammable levels in the slurry tanks.  And, critically, DuPont personnel did not properly isolate and lock out tank 1 from tanks 2 and 3 prior to authorizing the hot work.  The flammable vapor was able to pass through the overflow line into the tank the welder was working on, unknown to him or to the operators who signed off the hot work permit.”

Noting the CSB issued a safety bulletin on the dangers of hot work in March 2010, CSB Chairperson Rafael Moure-Eraso said, “I find it tragic that we continue to see lives lost from hot work accidents, which occur all too frequently despite long-known procedures that can prevent them.  Facility managers have an obligation to assure the absence of a flammable atmosphere in areas where hot work is to take place. Explosion hazards can be eliminated by testing inside tanks as well as in the areas around them.”

This is the 2nd fatal accident involving DuPont locations in the USA recorded in 2010.


Manual Handling in Mining

Graham Marshall - Tuesday, February 01, 2011
We all know that manual handling jobs are a significant cause of relatively low consequence but high frequency incidents, costing individuals and organizations significant harm.

The consequences for workers harmed during manual handling tasks can be quite debilitating and depressing.

Anyone experiencing a bad back will know what I mean.

There is no need for me to re-invent the wheel here on manual handling.

Here's a link to a reasonable PowerPoint slideshow from the WA Department of Resources Safety that covers the main themes quite well.

Safely bend your back

Graham Marshall - Wednesday, January 19, 2011
I'm always reasonably happy when I've attended a training course and learned about or got ideas for two or three new things.
When I attended a manual handling training course a while ago I picked up a really good tip that forms today's safety "one per-center".

A very common cause of back pain occurs when a person performs the simple act of bending over to pick something up off the floor.

This situation can occur when you're walking along and see a piece of litter lying on the ground - so you bend down to pick it up.

I'm sure many of you have experienced the sudden stabbing pain and "freeze-up" in the spine that can result from this very innocuous behaviour!

The solution is a simple safety "one per-center".

Any time you're going to bend your spine to reach something at ground level, ensure to make these three behaviours first:

  1. Standing in the direction in which you're going to bend, move your left leg about 18 inches in front of your right leg;
  2. As you begin to lean forward, brace your left arm against the lower thigh of your left leg;
  3. Reach down with your right hand.


Note the above behaviours describe the correct process to be followed by right-handed people.  Sinister people (left-handers) will need to use the reverse body positioning.

The tip is simple - always put your hand on your knee when bending to reach something on the floor.

Safe Manual Handling

Graham Marshall - Tuesday, January 18, 2011
Manual handling activities are such an everyday routine yet they tend to cause such a large percentage of first aid cases, medical treatment cases and lost-time injuries that it's just not funny.

And most manual handling jobs are simple to manage at the level of the easy personal behaviours that I call "one per-center's".

One per-center's are the easiest formal safety actions we must take or informal safety choices we should make that help to keep work places safe and demonstrate a mature safety culture exists in practice.

The simple "one per-center's" for manual lifting include:


  • Assess the size and shape of the load before lifting it;
  • If at all possible or practical, use an alternative method to lift (e.g., use a trolley or forklift);
  • Hold the weight close to your body;
  • Bend your knees and keep your back straight;
  • Avoid twisting your body when lifting;
  • Ensure you can see over/around the load being carried;
  • Ask for of offer help when manually-lifting objects;
  • Use carrying handles if available on the package to be lifted;
  • Wear the correct PPE; and
  • Plan your lay-down area.

In Australia, the National Standard for Manual Working [NOHSC: 1001(1990)] together with National Code of Practice for the Prevention of Occupational Overuse Syndrome [NOHSC:2013(1994)] offer further formal guidance on managing manual activities.

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