IPAF member alert – Learning from Incident: Post-Maintenance Verification
Overview
IPAF has been made aware of a recent incident involving the uncontrolled descent of a boom-type MEWP during operation. The investigation identified that the event was linked to a maintenance-related issue following the replacement of a primary boom cylinder. No serious injuries occurred. The companies involved responded promptly, undertook a detailed investigation, and shared the findings to support wider industry learning. This notice highlights key lessons that are applicable across all powered access equipment.
Based on the information shared with IPAF, the incident highlights the importance of robust post-maintenance verification to confirm that replacement components are correctly installed, configured, and checked before return to service.
What Happened (Summary)
- A MEWP experienced a sudden, uncontrolled descent during operation
- The incident occurred following the replacement of a primary boom cylinder
- A transportation seal was found to have remained in place following installation (Fig 1)
- The investigation indicated that the retained transportation seal may have affected the integrity of the hydraulic connection
- The machine had been subjected to inspections prior to use; the issue was not identified during the checks completed before use.
Key Learning Points
- Component replacement introduces additional risk if not completed and verified correctly
- It is recommended that additional notices or information is included and fixed to the part to highlight that transportation seals are fitted
- All work must be carried out in strict accordance with manufacturer instructions
- Non-routine maintenance tasks require appropriate competence and verification
- Post-repair checks must confirm correct configuration and assembly
- Inspection alone may not identify latent issues introduced during maintenance
Key Messages for Industry
- Treat maintenance and repairs as safety-critical activities
- Ensure structured post-maintenance verification processes are in place
- Follow manufacturer instructions without deviation
- Share learning from incidents to improve industry safety
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