Professional Documents
Culture Documents
Hyd Injection
Hyd Injection
06/10/29
256-162
Prelude To Incident
Failure to warn: The Miner and his partner did not identify the
potential of such actions.
Failure to make safe: The McLean Bolter was not in a zero energy
state as per site requirements.
Improper placement: The Miner was manually searching the cluster
of pressurized hydraulic hoses with his hands
Improper placement for the task: The Manufactures
recommendation is for “visual inspection only”.
Servicing of equipment while in operation: The request for
hydraulic activation to locate damaged hose when the Miner was not
certified to service or inspect equipment.
Failure to use appropriate PPE: The operators manual states “use a
piece of tin or cardboard “ for inspection of hydraulic leaks.
Root Causes
Lack of knowledge: The Miner had not received any
documented training or been made aware the potential hazards
associated with the McLean Bolter.
Lack of skill: The Miner was not adequately trained in the use,
operation and hazards of the McLean Bolter.
Inadequate Work Standards: The company had at the time,
no written procedures for the inspection of high pressure lines.
There was at the time no mention in the company orientation of
the risk factors when dealing with high pressure hoses and
maintenance of them.
Hose Separator Tool