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5Why Points to Engineering Controls

The truck was fitted with Patchell bolsters, specifically engineered and time proven. However, the investigation revealed that the extension pins were retrofitted by the original owner of the vehicle, and someone other than Patchells. Incorrect installation has allowed the pin to extend beyond its design limit and therefore not lock into place correctly. It has subsequently dropped down into the bolster, at some time during transit.

Investigation - Some Key findings...

The Patchell ‘extension pin design is robust and sturdy and will perform as intended if fitted according to the manufacturer’s plans – this one was not!

  • Experienced drivers tell us that using an incorrectly fitted pin, such as the one in this incident, would give a sense (feel) of having the ‘wrong key in the lock’.
  • Logs must be loaded according to the ACOP standards – no exceptions. Carting a lighter species of logs e.g. Douglas Fir, is not an excuse for overloading or poor loading.

 

Managing Risk – Please Consider!

  1. When using new or used equipment both Owners and Operators have duties to ensure that devices are properly installed, can activate or lock-out correctly, and be used safely.
  2. PCBU’s that design, manufacture, import, supply and install plant, substances, or structures must ensure such are safe to use and fit for purpose – HSW Act 2015 s. 36–43.
  3. Immediately report faulty equipment taking it out of service until corrected or repaired.
  4. Use this alert as an occasion to review all safety devices especially on extension pins.

View this article in Safety Bulletin 122