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2015 - Lateral Learning LL46 - LTI#32 - Amputated Fingers
A crew was conducting function tests on a valve on a roof top. A mechanic on the roof had his fingers in the valve as he attempted to reposition the valve. The engineer on the roof shouted to the technician at ground level to position himself nearer to the isolation valve ready to activate it, but the technician misunderstood the instruction and instead operated the valve. This caused the valve to close amputating the tips of two of his fingers.
- Never compromise safety for production - Ensure you do not bypass the PTW controls - Always follow management of change procedure - Always ensure effective communication
Always ensure clear communication between operators

Category:Second AlertsDocument Type:Safety
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