On 29 October 2020, a contractor service mechanic serviced a generator that provided power to a mine village. The generator was on a hire agreement with a third party supply company, which is a common arrangement for mines in Western Australia.
The service mechanic completed a general service of the 300kVA generator, de-isolate it and brought it back online. He then conducted post service inspections and clean up, including wiping up oil and grease marks with a rag.
When the service mechanic leaned into the generator enclosure with a rag in his hand, it appears the rag and his hand were drawn into the rotating radiator fan blades causing serious injuries to his thumb, index and middle fingers.
Direct causes
The service mechanic's hand contact the rotating radiator fan blades while working near the underside of the fan guarding with the machine running.
Contributory causes
- The service mechanic was cleaning up inside the generator enclosure with the engine running.
- There was a gap in the underside of the guarding around the radiator fan.
- It is possible for a loose rag to be drawn into the fan blades thereby pulling a hand in through the gap in the guarding to contact the moving blades.
- Risk assessment conducted by duty holders had not identified the risk of entanglement posed by the gap in the fan guarding.
- The work procedure for servicing and inspecting the generator was not clear in terms of job sequence and isolation requirements.
- Monitoring processes were not undertaken to confirm that standards/safe work procedures were followed (e.g. audit, task observations, site inspections).