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<big><b><u>Please Review</u></b><i>.<br>
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.</i></big><i><big> 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</big>.</i> <br>
<br>
<p><b>Statement:</b> 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. </p>
<p><b>Discussion:</b> 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.<br>
<br>
The proper ladder for this work was available within the facility,
but was never obtained.<br>
<br>
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." </p>
<p><b>Analysis:</b> 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.<br>
<br>
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.<br>
<br>
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. <i>(Latent
Organizational Weakness)</i><br>
<br>
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. <i>(Latent Organizational Weakness)</i><i><br>
</i><br>
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. <i>(Error Precursor) </i></p>
<b>Actions:</b> <br>
-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.<br>
<br>
-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.<br>
<br>
-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.<br>
<br>
-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.<br>
<br>
-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<br>
<br>
<br>
<pre class="moz-signature" cols="72">--
Henry Robertson
DSO, Engineering Division
Safety Systems Group
PH# - 757.269.7285
FAX - 757.269.7352
<a class="moz-txt-link-freetext" href="http://www.jlab.org/accel/ssg/">http://www.jlab.org/accel/ssg/</a>
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