Investigate a tyre changer near miss and run a toolbox talk

What is going on

At the Geelong tyre centre the bead breaker on the tyre changer activated while the operator's hand was near the blade. Nobody was hurt, but the guard was found bypassed with a cable tie. The event is logged as HZ-26-035 in the Incident and Hazard Register with the machine isolated and the investigation open. The WHS and Quality Coordinator is at another site all week and has asked you to lead the investigation, find the reasons the guard was bypassed, propose corrective actions that address the cause rather than blaming the operator, and prepare a toolbox talk for both sites. The Plant and Equipment Register shows the machine's inspection history, and the hierarchy of control in the WHS Policy applies to any control you recommend.

Your brief

Investigate the near miss using records and interviews, identify immediate and underlying causes, recommend corrective actions ranked by the hierarchy of control, update the register, and prepare and record a toolbox talk that consults workers on the findings.

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 WHS Policy and the HZ-26-035 entry in the Incident and Hazard Register, then update the status and add yourself as investigator.
• Review the tyre changer's record in the Plant and Equipment Register, including inspection dates, previous defects and who is responsible for it.
• Plan and conduct interviews with the operator and the supervisor, asking why the guard was bypassed and what pressures or equipment problems contributed, and record the answers.
• Analyse the evidence to identify the immediate cause, the underlying causes and any gaps in training, maintenance or supervision.
• Recommend corrective actions ranked by the hierarchy of control, with an owner and a date for each, and estimate the cost where a change to plant is proposed.
• Update the Incident and Hazard Register entry with findings and actions and set the status to Action in progress.
• Prepare a toolbox talk on the Toolbox Talk Record Template covering guarding, machine isolation and the reasons the bypass happened, and deliver it to a group of workers.
• Write a one-page investigation report for the Dealer Principal that includes the findings and a recommendation on whether the event is notifiable to WorkSafe Victoria.

What someone in this role would produce

• Investigation report with causes and corrective actions
• Updated Incident and Hazard Register entry
• Completed toolbox talk record with attendance
• Plant and Equipment Register review notes