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Fluid Power Safety Alerts


(Ref. No. SA-019)

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Description of the accident:

A machine operator was fatally injured while he was attempting to bleed trapped air from a hydraulic cylinder located on an automated forming machine.

How the accident occurred:

The injuries occurred when he opened a bleed-to-atmosphere type air-bleed valve located on a hydraulic cylinder, causing high pressure hydraulic oil to be injected into his hand.

Contributing factors:

The Fluid Power Safety Institute™'s unofficial accident analysis and opinions are based on discussions with the maintenance personnel, and an inspection of the machine.

Machine operator is injected with hydraulic oil.
1. Improper Procedure
a. The operator attempted to bleed air from the system. This should have been a maintenance responsibility.
b. No Job Safety Breakdown (JSA), or Job Safety Analysis (JSA) was written for this procedure.
2. Training
a. The process for ensuring that employees have received proper training and reinforcement is inadequate because several key elements are missing in the training process.
b. Training of supervisors does not include key safety issues for this procedure.
c. Air-bleed training was not specific for this job.
d. Maintenance personnel have only on-the-job training in hydraulics.
e. Operators, mechanics, and supervisors receive no training in hydraulic safety.
3. Unreported Incidents
a. Similar incidents have occurred while bleeding trapped air from a hydraulic system.
4. Inexperience
a. The operator had no experience with hydraulics, or any knowledge of how to safely bleed trapped air from a hydraulic system.
5. Production Demands
a. Production demands were so high that, to save time, basic service and repairs were left to the operator.
6. Equipment Design
a. Manual bleed-to-atmosphere air-bleed devices lend themselves to this kind of accident. Even a trained person is at risk. Alternative air-bleed devices, such as automatic air-bleed valves, closed-loop ball-valves, or Safe-T-Bleed® should be specified.

Conclusion -

This type of accident can also be caused by the common practice of "cracking" high pressure connectors and/or transmission lines to "check" for pressure and/or flow.

High pressure injection injuries of the hand (body) have been recognized by the medical profession as being devastating. Oil based solvents which include grease, hydraulic oil, and paint, are particularly hazardous. According to one of the studies I read, reported rates of amputation vary from 16% to 48%.

Although appearing innocuous at presentation, high-pressure injection injuries have a reputation for being associated with infection, disability, and a high rate of amputation-

Oil injection point of entry.
Major incision of hand required to remove hydraulic oil.


TAKE THESE TYPES OF ACCIDENTS VERY SERIOUSLY!

Suggestions on how to prevent this type of accident:
a. Train everyone who works on and around your hydraulic systems- this includes operators, supervisors, and plant managers.
b. Only allow trained, authorized personnel to execute service and maintenance functions on your hydraulic systems.
c. Include safety in machine specifications, i.e. design for safety.
d. Have suitably qualified persons write Job Safety Breakdowns for all "special skills" tasks.
e. Install "closed-circuit" pressure verification and bleed-down devices in all areas where energy can be stored in your hydraulic systems.

Give us your feedback
The accidents we report are real, and the victims are real. The safety guidelines we provide are to help companies and individuals work safely with hydraulics. All guidelines we provide are general, and are not intended for one specific hydraulic system or machine.

WHEN YOU PURCHASE HYDRAULIC-POWERED MACHINERY AND/OR EQUIPMENT, WE HIGHLY RECOMMEND THAT ONCE YOU DETERMINE THAT IT CAN DO THE WORK YOU WANT IT TO DO, YOU THEN DETERMINE HOW MUCH SAFETY HAS BEEN BUILT INTO IT BY THE MANUFACTURER. IN ADDITION, WE RECOMMEND THAT YOU, WITH THE INPUT FROM YOUR OPERATORS, MECHANICS, ENGINEERS, PRODUCTION PERSONNEL, AND SAFETY DEPARTMENT, FORMULATE A LIST OF MINIMUM SAFETY STANDARDS FOR THE EQUIPMENT YOU PURCHASE. ALTHOUGH WE LIKE TO BELIEVE THAT MOST MANUFACTURERS ARE CONCEREND ABOUT SAFETY, SOME BELIEVE THAT CERTAIN SAFETY MEASURES ARE AN UNNECESSARY EXPENSE. WE FURTHER RECOMMEND THAT ALL THE SAFETY STANDARDS AND RECOMMENDATIONS THAT YOU DEVELOP SHOULD BE REVIEWED BY YOUR SAFETY DEPARTMENT, ENGINEERING DEPARTMENT, AND BY THE RESPECTIVE MACHINE OR EQUIPMENT MANUFACTURER PRIOR TO MAKING THEM POLICY - TOTAL SAFETY CAN ONLY BE ACHIEVED WITH A TEAM EFFORT.

CAUTION!
The Fluid Power Safety Institute™ does everything possible to insure that the information and drawings contained in these documents is accurate, and the procedures are deemed safe and reliable. However, these are general recommendations only and might not be applicable to all situations.

You MUST have your engineering department and service department read these recommendations and make the necessary changes for your specific application.

The Fluid Power Safety Institute™ is not responsible for actions taken by untrained and/or unauthorized persons. ALL hydraulic system service, repair, and troubleshooting should be done by trained, authorized persons ONLY.


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