"surgeons intervened and had to perform an amputation on the spot"

On one of our plant visits the plant manager said “I’ll let you speak to one department, which one you want to speak to?” We replied “the maintenance department”. The plant manager asked “Why? Your products are used in the casthouse not the maintenance department.” We replied “because more fatalities occur in the maintenance department than any other department.” After we gave our presentation to the maintenance department (dealing with only incidents involving maintenance personnel) the plant manager asked if we can speak to every department in their plant. We tell you this story to emphasize that we acknowledge the hazardous work maintenance department personnel do on a daily basis. No other department comes into contact with more hazards during their work day than a maintenance. Here is an incident from earlier this year that we failed to post. Sadly, there many, many incidents we don’t post. Here is the incident:

An employee of aluminium smelter died one night around 23 h 30 during August 2018, the forty-year-old found himself stuck between two gimbals on a car line.

Major resources have been deployed, including a fire brigade roadside van. Two teams of surgeons intervened and had to perform an amputation on the spot.

The victim was transported by helicopter to hospital 85 kilometers away. The electrician died shortly after.

The Aluminium Plant Safety Blog offers our condolences to the deceased worker’s family, friends, and coworkers.

We were unfamiliar with the term “gimbals”. One of our industry contacts provided this definition “gimbals are part of the mechanism to have the rollers work.” Hopefully that is correct. Regardless, we make the assumption that the deceased worker failed to acknowledge that the gimbals could move, or had properly lock out tag out or safely isolated them and they still moved.

In our experience we have observed incidents where a maintenance worker properly lock out tag out the machinery and still whatever potential energy somehow got released. The worker was killed. We know of numerous incidents where this has occurred. So in response we have been telling maintenance department managers that if they have equipment where they are locking out a hydraulic ram, machinery, etc. that could move and physically touch their workers to add one last stop gap measure. Insert some custom designed fabrication e.g., crane rail) that if all other measures fail this may allow the workers to escape. Please note, this idea of using a fabricated item to prevent the release of potential stored energy is not a replacement for the lock out tag out or safe isolation procedure. We tell managers that they need to inspect and enforce their current safe isolation procedures.

Not surprisingly we spoke to a few hundred maintenance workers and specifically mentioned an incident similar to this story. We hope to find out what was the root cause of this incident and will update this post accordingly.

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