[Hallb-engineering] Fwd: Lesson Learned "Ladder Use Injury at SLAC"

Douglas Tilles tilles at jlab.org
Thu Sep 26 07:35:42 EDT 2013

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From: mbailey at jlab.org
To: mbailey at jlab.org
Cc: robertl at jlab.org
Sent: Wednesday, September 25, 2013 5:00:12 PM
Subject: Lesson Learned "Ladder Use Injury at SLAC"

	Ladder Use Injury at SLAC 	
Statement of Lessons Learned 
This is an example that even a low elevation fall can result in serious injury. Discussion of Activity 
In August 2013, while descending a ladder, a SLAC employee fell two feet which resulted in a fractured vertebra.  Three SLAC employees were entering a Cooling Tower basin to perform a visual inspection of heat exchangers. A six foot extension ladder was used to enter the three and a half foot deep basin. The safety representative, who was part of the group, stated that holding the ladder to mitigate the fall hazard would be an effective control measure. The three employees entered the tower with one employee holding the ladder and began their inspection. After inspecting the tower on the east side the employees moved to the west side of the tower. At this time, a fourth employee decided to enter the basin of the tower. The fourth employee did not confer with the other three employees and was unaware that the ladder should have been held as the control method. The employee who had served as the ladder attendant was a few feet away from the ladder and had his back turned to the ladder when the fourth employee approached. The fourth employee began to climb down the ladder.  During his descent, the ladder slipped out from underneath the employee causing him to fall. The fall resulted in the employee experiencing pain in his right arm and lower back. Analysis 
The initial x-rays on the day of the fall did not show a fracture.  The SLAC Occupational Medicine physician reported the results of a follow-up MRI to SLAC ESH&Q on September 11 that revealed a T12 vertebra complex compression fracture. The fracture is presumed to be the result of the fall. Recommended Action 
None for Jefferson Lab at this time.
Ensure a ladder�s physical condition is adequate for the job.  
Ensure proper set-up (i.e., ensuring a sound foundation upon which the ladder is positioned). 
9/25/2013 4:35:34 PM by Bailey, Mary Jo 
Submitted to with current �SAF307: LADDER SAFETY training 	
Summary 	Lesson ID: 	753 
	Status: 	OK 
	Doc ID: 	2013-JLAB-753 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	9/25/2013 4:34:51 PM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	9/25/2013 4:35:34 PM 
	Source: 	OTHER 
	Location: 	SLAC 
	Cost Savings: 	
	Contact: 	Ned Walker � JLab Ladder SME x6638 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

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