The US Bureau of Safety and Environmental Enforcement (BSEE) has released Safety Alert 463: Adaptation and Modification of Tool Results in Injury.
The alert describes how a worker was recently injured while attempting to install a hydraulic line on a pipe handling machine during offshore energy operations. The worker determined the combination wrench on hand was too long for the job and therefore placed it into a vice to manually shorten the length by using a hacksaw.
The worker subsequently cut a gloved hand with the sharp edge of the altered wrench handle, resulting in a laceration requiring sutures.
The operator’s Incident Investigation Team identified the following causal factors:
• The worker did not pause or stop work to consult with a supervisor when the job scope changed and/or the proper tool was unavailable. The decision to modify the combination wrench was not discussed with the supervisor before modifying the tool.
• The worker did not explore the potential for other avenues and/or options for locating the proper tools (i.e., checking with other work groups).
• A proper wrench that would fit in the tight area was not readily available on the rig floor.
• When the worker decided to alter the hand tool, they chose a readily available hand saw versus a more appropriate/potentially safer method, i.e. a bandsaw.
BSEE recommends that operators and their contractors consider reviewing safety alerts with all relevant employees, review the corrective actions implemented by the operator and ensure proper tools are available.
It also recommends reviewing all Hazard Analysis policies and procedures to ensure hazard identification and mitigation card / compass card is used and understood.
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