Poor Equipment Design & Human Error

Description of Incident

Electro-magnetic on magdrill accidently turned off, which released the tool from its position and entrapped the operator’s hand between the tool and bottom joining plate.

Poor ergonomic design of button controls enables an easy and mistaken pressing of the wrong button. Above each button is a symbol (left side a power symbol and right side a magnetic symbol), however, these do not represent the buttons directly below them.

Immediate Cause: Human Error - Pushing of the wrong button.

Root Cause: Poor design of equipment

Good Practice Guidance

Ensure equipment is selected with user ergonomics and familiarity with the equipment in mind.