Investigate a forearm laceration on the hindquarter line

What is going on

Last Wednesday a slicer on the hindquarter boning line cut their left forearm above the cut resistant sleeve while trimming a rump and needed four stitches. The initial report is in the Incident and Hazard Register as INC-26-118. The People and Safety Manager wants you to lead the investigation. Early information suggests the sleeve did not cover the area between the glove and the elbow, the knife had not been exchanged since the start of the shift and the station work instruction does not mention sleeve length. A similar minor cut occurred on the same line in July. The plant has had one lost time injury this quarter and the health and safety committee has asked for the findings.

Your brief

Plan and conduct the investigation, establish the sequence of events and root causes using the five whys, recommend corrective actions with owners and dates, and draft the revised work instruction, then report to the People and Safety Manager.

Work through it

You do not need to do it all. Doing a few of these will show you what the work is like. Your ticks and notes stay on this device.

• Read the Occupational Health and Safety Policy and the Knife Safety, Sharpening and Personal Protective Equipment Procedure and list the controls that apply to the station.
• Prepare an investigation plan: who you will interview, what records you will pull from the Incident and Hazard Register and the Training and Competency Matrix, and what you will inspect at the station.
• Using the interview notes and photographs supplied by your assessor, write the sequence of events from the start of the shift to the first aid treatment.
• Apply the five whys to establish at least two root causes, distinguishing immediate causes from system causes such as the work instruction gap and sleeve sizing.
• Recommend corrective and preventive actions using the hierarchy of control, each with an owner and a due date, and update INC-26-118 in the register to Actions open.
• Draft the revised station work instruction on the Work Instruction Template, including personal protective equipment, hazards and controls and the knife exchange rule.
• Prepare a Toolbox Talk Record for the boning room crew explaining what happened, why, and what changes, without naming or blaming the injured worker.
• Write a one page report to the People and Safety Manager and the health and safety committee.

What someone in this role would produce

• Investigation plan
• Sequence of events and five whys analysis
• Corrective action plan and updated register entry
• Draft revised work instruction
• Toolbox talk record and one page report