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Finger Pinch, Hand Placement Location (An open area where hand fits…
Finger Pinch
Hand Placement Location
An open area where hand fits
Guarding / Shielding removed to complete work
Removal of guard required to complete task
Work Instruction step
Perceived to be safe place for hand.
Rotor Lock was applied
Habit-Always done this way
Trained this way
Policy
Working In Area
Removal of coupler
Steps towards removal of IMS shaft
IMS required changing.
No thought of hand placement.
Tech used to working in the area
Coupler Checks and removal common task for annual service and other tasks.
Did not expect parts to move
Risk perception
Rocking of Rotor-Movement
Causes movement in the high speed shaft from gear box
Secondary Rotor lock was not installed
Work Instruction was not followed
.
Slipped and used hand to Steady
Using as hand point to climb out
Someone Held Hand there