LTI Amputation of finger Printer W&H 1209 Chihuahua August 27.

04

Environment Equipment

Broken Screw
Management

Risk Report
System Guard Missing

Communication Tampering Safety Devices

PPE
Uncertainty
Lack of maintenance
Operating Machine

LTI FingerAmputation
Maintenance high work load Poor supervision

Low motivation
Tolerance to violations

Limited number of employees No procedures for fixings on Operating

Lack of Training machines

Confidence Excess Production bonus system

Overtime / Working
on days off

Lack of Commitment Lack of working procedures

Work Stress
Lack of procedure for reporting failures to
SUSAs Negligence maintenance
Low Moral
Lack of safe work procedures
Empowerment

Personnel Inadequate Leadership Procedures

Safety Culture

Actions Defined :

1. Reinforce preventive maintenance program

2. Installation of missing guards
3. Reparation of broken screw
4. Implement Risk Identification Reports
5. Safety IDs to machines
6. Elaboration of safe work procedures
7. System for reporting failures to maintenance
8. Reinforce Commitment
9. Implement OTTO
10. Reinforce supervision at all levels
11. Reinforce leadership
12. SHE culture reinforcement
13. Work load and stress
14. Safety Shutdown
15. Presentation of accident to all local employees by manager
16. Implementation of actions from Golden Rules Audit
17. Elaboration of Machine Risk Assessment