[Eng-div] Lessons Learned

[Henry Robertson]

*_Please Review_*/.
Below is an excerpt from a near-miss incident at another DOE facility. 
I've only included the sections that seem important to JLab 
staff.//Although the event seems simple, as you will see a variety of 
circumstances and actions built into a near miss situation. Please read 
and discuss this with your fellow workers./

*Statement:* Urgency does not negate the need to work safely. In some 
instances, responses to urgent work may introduce new or additional 
hazards that need to be addressed and mitigated before work commences.

*Discussion:* Recently, a worker incorrectly used a 6-foot portable 
A-frame step-ladder to access equipment. The ladder was used in its 
folded position, its top cap was placed against a structure supporting 
the equipment being accessed, and the worker stood on the top cap. This 
occurred twice during the evolution. It is a violation of OSHA 
regulations to utilize a portable A-frame ladder in this way.

The proper ladder for this work was available within the facility, but 
was never obtained.

NOTE: The top cap is the horizontal crosspiece at the peak of an A-frame 
ladder. The top step, the highest step the user can stand on safely, 
typically is the third step below an A-frame ladder's top cap. On newer 
ladders, the second step below the top cap often is marked with a label 
stating "Do not stand at or above this level."

*Analysis:* During the analysis that followed this event, it was 
discovered that several hazards (or risk factors) existed during work 
planning and execution that were not properly recognized or controlled. 
Long hours for one worker (who was not properly approved for the work), 
a readily available six-foot A-frame ladder (which was too short for the 
task), supervisors' unfamiliarity with the work to be performed, and 
management statements to the workers that created a sense of urgency to 
complete the job are all risks that were not adequately identified and 
controlled.

On occasion, urgent work must be accomplished. However, the risks 
associated with conducting any activity, regardless of urgency, must be 
completely understood and controlled. Newly- created hazards must be 
controlled in order to protect the workforce and the environment.

The Work Permit for this operation was reissued from a previous version. 
Only one of the two workers assigned to perform the work was familiar 
with the activity. The work was performed without the industrial safety 
or industrial hygienist conducting a pre-job briefing or site walk-down 
review. A proper task preview (which includes checking and selecting 
appropriate PPE and equipment for the job), procedure adherence, pre-job 
briefing, questioning attitudes, peer-checking and verification are 
tools that could have prevented this event. Utilizing a 6-foot ladder 
poses very little danger if the appropriate ladder type is selected for 
the task, is used in the manner for which it is intended, and is used 
following the guidelines for proper ladder use. /(Latent Organizational 
Weakness)/

The newly-assigned responsible individual (RI) had not participated in 
this operation before and the worker on the ladder had only witnessed 
the operation once before, using a similar ladder in a similar way. 
Also, the worker on the ladder was being "borrowed" from another 
directorate. It was determined that both individuals lacked adequate 
understanding of this particular evolution. The workers assumed that 
this was the proper way to conduct this work. /(Latent Organizational 
Weakness)//
/
Lack of knowledge; minimal turnover communication between the new RI and 
the previous RI; the worker performing the task never having performed 
it before (he only witnessed it previously and was the available person 
most familiar with the equipment's operation); time pressure to complete 
the work; inadequate work planning by failure to identify and control 
all associated hazards; and lack of a questioning attitude by the 
workers involved. /(Error Precursor) /

*Actions:*
-All workers should be properly trained and authorized to conduct 
assigned work. Work control documents that contain "feedback and 
improvement" sections should be reviewed more thoroughly when resuming 
work to ensure that all hazards are controlled.

-If the work control process requires specific disciplines to be present 
for pre-briefings, walk-downs, etc., then work should not commence until 
they have had a chance to properly and thoroughly review the job.

-The proper equipment has to be utilized for the work. If the proper 
equipment cannot be located, then work shall not proceed until it is 
made available.

-Communication between management and workers needs to be clear and 
concise. If work is planned to be completed in an urgent manner, then 
all risks and hazards introduced by the urgency must be fully 
identified, understood and controlled.

-Stop Work authority is a control available to all workers to prevent 
mishaps. All workers must be vigilant in stopping work if there are 
newly- recognized hazards that have not been properly controlled


-- 
Henry Robertson
DSO, Engineering Division
Safety Systems Group
PH# - 757.269.7285
FAX - 757.269.7352
http://www.jlab.org/accel/ssg/

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