©Anheuser-Busch InBev

Where ? What ? Why (Causes) ?

When ?

Corrective and Preventive Measures

Injury / Damage 3 Fingers hand broken

SAFETY ALERTSAFETY FIRST !

Zone: BNFLCountry: BelgiumPlant: LeuvenDepartment: PackagingEquipment: Lachenmeier foiling machine

Date: 27.09.2014Time: 11:20 PM

1. Technical:• Hoist arm not electrically driven, needs

manual assistance to move for & back-wards, forcing the operator to be in the line of fire

• Hoist: hooks not protected with safety latch to secure & block the load against slipping from hooks – just an open hook

• Axis of hoist not equipped to prevent foil role to glide left-right on the axis

• Fixation points of the foil stand not well designed: operator needs to support with his hands to ensure a smooth gliding of the role in the fixation points

2. Organisational: • Change foil role not included in risk

assessment of pallet stretch machine• No OPL on correct way of working• Not included in Trainings matrix

Packaging3. Behavior:

• Risk underestimated by operators: working in pairs increases risk, because only one operator is in control of the hoist

• VPO.SAFE.3.2.02. Risk Assessment• Perform risk assessment on this task: Avoid lifting of foil roles of stretch foil-

evaluate if 2-level of layers in foil stand of the stretch machine is needed and define if roles only at ground level are possible

• VPO.SAFE.3.1.14. Safety Training• Create OPL on this task: avoid working in pairs- only one operator- operator

must stay out of line of fire• Ensure every operator is trained on the exact way of working• Ensure this OPL is included in trainings skills matrix, related with operation of

the Pallet Stretch Machine • VPO.SAFE.3.1.03. Lifting equipment• Make necesssary changes to the lifting equipment:

• Adapt axis of foil role so that role is fixed on the axis, cannot slip away• Hoist arm must become electrically driven• Hoist hook must be foreseen of safety latch and system to open this

latch in a safe way• Fixation points of the foil stand of the pallet stretch machine must be

adapted to avoid manual intervention – avoid hands of operator are in line of fire (e.g. install a funnel)

• Operator needed to change 250 kg foil role of the upper layer of the foil stand of the pallet stretch machine

• He needed first to lift the new 3 meters width role with a hoist until a height of 2 meter & after that, make sure it fits in the fixation points of the foil stand.

• Because the hoist is not electrically driven, operator needs to guide the role with his hands during lifting.

• Second operator came by to help in this lifting process, so both operators were guiding manually-one at each side of the role- the role in the exact position.

• During lifting, just before the role would fall into the fixation-points of the foil stand, the role with the axis suddenly fell out of the hoist: operator’s hand was hit

©Anheuser-Busch InBev •Slide n° 2 •Slide n° 2

Safety: LTI Pallet Stretch machine•Hook hoist NOK

•Fixation points on frame

•Load must be manually put in place – hoist not electrical driven

•Hands operator in line of fire

Fixation point not adapted – manual intervention needed in line of fire

©Anheuser-Busch InBev •Slide n° 3 •Slide n° 3

Safety: LTI Pallet Stretch Machine actionsHook hoist NOK: no safety latch

Fixation points on axis to avoid role slipping away

Fixation point not adapted – manual intervention needed in line of fire

Hook not fixed on axis, role can slip away

Hook hoist OK: with safety latch

Fixation point adapted: funnel was created- axis glides more smoothly into fixation – no manual intervention needed

Hands operator in line of fire

Funnel welded on

Release mechanism added to the hoist: to free up safety latch & unhook the hoist from axis, without manual intervention in line of fire

Release arm down = safety latch closed

Release arm up = safety latch open