Summary of incident
In April 2016, a tyre fitter was positioning a hydraulic bead breaker in preparation for breaking an inner tyre bead on a water cart. The worker was holding the bead beaker in his right hand and the remote control pendant for the hydraulic power pack in his left hand. He attempted to gain extra length in the pendant control cable by flicking it over the power pack. This action activated the hydraulic power pack, by either knocking the pump toggle switch to the 'on' position or depressing the pump 'on' button of the pendant. The sliding section of the bead breaker was set in motion and crushed three fingers on his right hand, resulting in partial amputations.
Direct causes
- The hydraulic power pack was energised with the control valve lever in the 'advance' position while the equipment was being positioned for operation.
- The tyre fitter inserted his fingers into the sliding section of the hydraulic bead breaker, exposing them to moving parts when it activated.
Contributory causes
- The equipment design does not encourage the correct positioning of hands nor restrict access to moving parts.
- There is no guarding to prevent inadvertent contact with moving parts nor labelling on the equipment to warn of the nip or crush point.
- Work instructions did not outline the controls for all hazards associated with the task.