an employee maintenance fitter was performing maintenance on a Magnuson Brush Washing
Machine. At the time the machine was not effectively isolated. . There was general confusion between the
maintenance staff regarding the functions of the various switches on this multiple‐drive motor machine. There
was no specific lockout procedure and the generic lockout procedures had not been followed.
The employees involved had no specific training in any isolation procedures. The employee's left thumb was
amputated when the machine started whilst he was working on it.
For this case study you are required to identify and explain;
Factors that contributed to the incident
Relevant standards, codes, regulations and what the actual requirements of those documents were
for the situation described by the case study
The actions you would put in place in the organisation to prevent the same type of incident from
occurring in the future and to meet compliance requirements