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Date – July 6, 2022
Source of issue –Safety: Factory Incidents
Description –
Over the course of the 2021/22 Financial year we had a record 7 Safety incidents in the factory. Over the previous 10 years we averaged 2 incidents per year. Refer to stats in the Business Process Status Report.
Here is a summary of the incidents:
1. 06JUN21: Riley Fynmore. Bandsaw nicked finger
2. 18AUG21: Andrew Jenner. Muscle strain, right leg
3. 15NOV21: Slater Clarke-Tessmann. Dropped anode on neck
4. 30NOV21: Slater Clarke-Tessmann. Bandsaw cut hand
5. 21FEB22: Slater Clarke-Tessmann. Zinc burn to right leg
6. Mid JUN22: Joshua Lambert. Burnt fingers on mould
7. FEB22: Joshua Lambert. Zinc burnt hand
Immediate action –Staff Training.
Root cause –Mainly inexperience
Corrective action –
Of the 7 incidents. 6 occurred to new staff who have limited experience.
BANDSAW: 2 occurred on the bandsaw. The 2 incidents (1 & 4 above) were the result of forcing the item being cut rather than letting the saw cut at its own speed. Incident no.4 was also the result of Slater not using a tool or pusher stick to enable cutting (as noted in the procedure), instead he used his hand, allowing it to get too close to the blade.
The immediate action for these incidents was training.
06JUL22: BL audited the Band Saw Cutting process. Refer to audit dated 06JUL22.GENERAL AWARENESS/INEXPERIENCE: Incidents 3, 5 and 6 were the result of inexperience.
Incident 3, the hot anode, which had just been cast should not have been carried above the shoulders.
Incident 5. Slater acknowledged that he did not wear the correct PPE. He had training to
Incident 6, instead of using the designated stairs to get to the casting platform, Joshua climbed up and put his hand on the hot mould to pull himself up. This entry point to the melt deck has since been blocked to prevent reoccurence.DIE COATING EXTRACTION: Item 7 was most likely caused as a result of a trial using a new Die Coating. As soon as the incident occurred, we stopped the trial. No similar incident has occurred.
The 2022/23 Financial year had 5 incidents, none of them resulted in lost time.
4 x Caleb Hunt + 1 x Josh Lambert. Caleb has since left CAA.
Both of these staff members are young and have limited experience. Decided to leave this open for another 12 months (OCT 24)The 23/24 Financial year saw 2 incidents.
1 Josh Lambert tripped while holding ladle. It was determined that a tidier workplace would reduce the liklihood of this type of incident.
1 Nathan Aberley was casting and molten metal went thru a hole in his pants causing a significant burn, ultimately requiring a skin graft. As a result of this incident, Clothing with holes is no longer allowed in the factory.
Verification –
Reported by –BL
Closed by –BL
Date closed –August 28, 2024