Safety Bulletin: Finger Injury While Moving Transformer
Summary of Incident
While moving a 369-pound transformer into an electrical room, a significant injury occurred. The team transported the transformer to the doorway using a pallet jack. However, due to a tight corner at the doorway, the transformer needed to be manually maneuvered into position. Two teammates were involved in this process: one was pushing from behind, while the other was pulling from the front.
As they attempted to guide the transformer through the doorway, a lack of clear communication led to a misjudgment. One teammate believed their colleague was clear and continued to move the transformer toward the door. Unfortunately, the other teammate’s hand was still near the door frame. This resulted in the teammate’s finger being crushed between the door jamb and the transformer, causing significant bleeding. The wound was immediately wrapped, and safety personnel were notified.
Root Cause Analysis
The primary cause of the injury was the movement of the transformer toward the door jamb while one teammate’s hand remained in a pinch point. Several contributing factors were identified:
- Lack of clear communication between teammates during the maneuver.
- No agreed-upon system of signals or designated leader to direct the move.
- Focus was placed on fitting the transformer through the doorway, rather than identifying pinch points or assigning specific roles.
The root cause was determined to be the absence of a detailed pre-task plan for moving heavy equipment in tight spaces. The team assumed the move could be performed as usual without the need for additional communication controls or assistance from a spotter.
Key Learnings
- Establish Communication Before Moving Heavy Equipment: Always agree on hand signals or verbal commands before beginning movement in confined spaces. Only one person should direct or call movements to ensure clarity.
- Identify Pinch Points and Assign Roles: Prior to any push or pull, determine where hands, feet, and bodies will be positioned at all times. Assign one person to lead, one to spot, and one to move as necessary.
- Stop and Reassess Tight or Awkward Moves: When movement becomes restricted or visibility is limited, stop and evaluate other options such as using pry bars, mechanical assistance, or adjusting positioning.
- Pre-Task Planning Matters: Even tasks that seem routine require a Job Hazard Analysis and/or pre-task discussion, especially when handling heavy, awkward, or high-risk items.
What We Can Do Better
- Perform task-specific planning prior to all heavy equipment moves.
- Reinforce “Stop Work” authority—if communication is unclear at any time, stop the task immediately.
- Utilize spotters and signalers to eliminate confusion when visibility or control is limited.
Remember: Moving heavy and awkward equipment requires more than physical effort, it demands a clear plan, defined roles, and constant communication. One missed signal or unspoken assumption can result in serious injury.