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Product related failure

Leigh W Sparrow, Publisher
Leigh W Sparrow, Publisher

September 24, 2018 - It is a well known and well documented fact that the vast majority of accidents/incidents are caused by operator error, while non maintenance/fatigue related product failures make up less than five percent of all incidents.

However, product failures do occur,  not only with lifting equipment of course but with high volume consumer products such as cars or washing machines etc which can be subject to a design issue that results in fatalities. Thankfully these are few and far between these days.

In the past two weeks we have had two serious cases of product related failures. Both are quite different but they do highlight the need to remain vigilant and to take nothing for granted. Let’s be honest, we all tend to take the reliability of our cars for granted - unless you drive a classic of course.

When I reached the age where I could drive, my father instilled in me the need to check the engine oil every time I refuelled, as well as checking the tyre pressures, water levels, and plug leads etc.. along with the brakes as I pull off. Who does that these days? I can’t honestly say that I heeded his advice religiously – but when he started driving this was essential and it was still relevant for the first few cars I owned. 

This faith we have in the modern car cannot of course be applied to equipment that lifts people or loads, given that a failure - no matter how rare - will cause a lot more harm than a car breakdown. However, cranes and aerial lifts are becoming more ‘automatic’ when it comes to outrigger and counterweight configuration or working envelope/overload protection. This demands that we be even more vigilant when it comes to maintenance or inspections, as operators will increasingly tend to rely on the safety systems and switch off their own monitoring - just as many of us do with the car sat nav.

In one of the two cases I referred to above, a tower crane in Melbourne dropped its load on the men working below, killing one and seriously injuring another. The operator did nothing wrong at all and was subsequently traumatised, as you can imagine. It turned out that a humble little split pin was missing from the critical lock-nut that secured the hoist rope dead end to the jib tip. Who was to blame? The tower crane erector? The manufacturer- it was the crane’s first job? - The person that last inspected it? The rental company? Or all of them? One assumes that the investigation might reveal this in the fullness of time, however it is far more important that lessons be learnt, rather than blame apportioned.

The manufacturer’s engineers arrived on site as soon as was possible and have actively participated in the investigation. It has also informed all of its dealers and major customers of the preliminary results of the investigation, and is waiting on Australia’s Worksafe to publish the final findings as is proper. It does raise a question on whether companies might consider that those doing inspections use a helmet mounted video camera or body cam - whether it be a final pre-delivery inspection, a post repair/maintenance inspection, a regular Thorough Examination, or in the case of a tower crane a post erection/pre-use inspection. This would prevent the casual ticking of a box on the inspection form that we all know does occur. Perhaps that is a step too far? Let us know what you think.   

In the aerial lift accident last week two men took the platform out to its full reach, causing a boom section to buckle. They were airlifted to hospital but mercifully were not seriously injured, partly due to them wearing harnesses and appropriate lanyards. The manufacturer has confirmed that the machine was a prototype and should only have been operated by a factory authorised person. This suggests that the automatic working envelope limiter was not enabled/installed as the two men had managed to telescope the platform into a part of the working envelope which had a platform capacity of less than 130kg – enough for one man and his tools capacity – not two hefty men with harnesses and lanyards etc.. It is very similar to another incident with a prototype spider lift at SAIE in Bologna a few years back, when a dealer and his customer were allowed to operated it alone and telescoped it beyond the range permitted for the outrigger configuration, causing it to overturn. One of the men - the customer - spent the night in hospital, but both men emerged relatively unhurt.

In the tower crane incident we understand that vital and, we assume, accurate information was distributed to dealers and owners within a week of it happening and possibly within 24 or 48 hours of the cause of failure being confirmed. Exactly how it should happen.

The second instance at Platformers Days, is slightly different. If it was a prototype there would have been no users, owners to inform - unless of course it was a failure of the overload system that was used on other machines? However as in the Bologna incident it does highlight the need for strict rules for such machines. Rules such as giving someone on the stand sole responsibility for holding the key to the machine, with instructions that only authorised personnel be allowed to use the machine who are fully briefed on its limitations. Of course, it could be argued that prototypes simply be banned from being used in such public venues?

The fact is that while product failures represent only a small proportion of accidents, some of them could be easily avoided with a) Simple rules governing the use of prototypes at public events and b) Good quality check lists for installations/inspections and maintenance of critical components - possibly carried out with video coverage?

One thing is for sure, much greater openness and a stronger focus on learning lessons is essential, rather than focusing on searching for someone to blame and prosecute.   

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Jim Hagan
9. November 2018 07:35

Eminently sensible article and the recommendation/suggestions should be taken up by the manufactureres and users.





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