[Hallb-engineering] Fwd: Lesson Learned "Danger of Objects Falling into Normally Occupied Areas � Various Locations"

[Douglas Tilles]

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From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Tuesday, January 6, 2015 10:00:26 AM
Subject: Lesson Learned "Danger of Objects Falling into Normally Occupied Areas � Various Locations"

Jefferson Lab Lessons Learned : Print Lesson 
	Danger of Objects Falling into Normally Occupied Areas � Various Locations 
	
Statement of Lessons Learned 
For a copy of the original report, see �Attachments� on Lessons Learned page. 

This Lesson Learned provides a variety of instances where items have fallen from heights into spaces normally occupied by workers. These events - all of which occurred in March through July of 2014 - serve as a reminder to employees to have 360-degree situational awareness for unexpected dangers.  In most cases, precautions had been taken before work started to protect passersby; however, workers inside the barricades were not considered in the precautions. 
Discussion of Activities 
On July 10, 2014, at the Strategic Petroleum Reserve West Hackberry location, a portable Honda generator weighing approximately 43 pounds was being lowered from a fixed elevated platform.  A three-fourths-inch rubber strand rope was double-knotted around the generator's handle to secure it; however, the knot loosened, and the generator fell 18 feet to the concrete floor.  No injuries were sustained, as a spotter had been posted on the ground level to prevent workers from entering the area. 

On July 9,2014, at Hanford River Protection, a 1.5-pound cat's paw nail puller fell 18 feet from a carpenter's tool bag and hit the ankle of a worker below. The area had been barricaded to prevent passersby from entering, but the carpenter was authorized to work within the barricaded boundary. 

On April 30, 2014, at the Strategic Petroleum Reserve West Hackberry location, a wrench fell from an elevated deck and hit the head of a construction worker seated below with enough force that it knocked his hard hat off.  The wrench had been stored in a collapsible tool bucket, however, it was not completely seated in the bottom of the bucket and fell out when the bucket was bumped. The worker - who had chosen to sit beneath the overhead platform -- was evaluated at Site Medical
and was determined to have no injuries. 

On April 4, 2014, at the Kansas City Plant National Security Campus, a piece of sheet metal, approximately one-quarter-inch thick, 10 inches long, and 5 to 6 inches wide, being used as an insulation shield on a chilled water line, unexpectedly fell 15 feet to the floor.  The metal landed near three contractors who were wearing safety shoes and hard hats.  It is unknown why the metal fell however it is suspected that a pressure surge may have caused the water line to move, thus causing the sheet metal to fall. 

On March 20,2014, at Los Alamos National Laboratory, part of a drop ceiling installed during a construction upgrade came loose, bringing a light fixture down with it and spilling several ceiling.  It was discovered that the anchors had not been adequate to attach to the cement ceiling, and the framing had not been installed in accordance with drawings.

On March 17, 2014, at Y-12's Building 9204-2, an area of concrete delaminated from the ceiling and
fell, striking a portable welding exhaust unit.  It then rebounded into a frequently used walkway.  Some concrete chunks were more than a foot in diameter and 2 inches thick.  Because that portion of the ceiling had been identified as degraded, the area below was controlled with marker tape and boundary markers.  Personnel entering the controlled area were required to notify the Shift Manager and to don hard hats before entry. However, the falling concrete spread into areas outside the existing boundary. 
Analysis 
Workers on scaffolds or ladders must ensure that boundary controls are established before work starts, be aware of their surroundings, such as loose tools, and practice good housekeeping so that nothing falls into the area below them.

Passersby or other workers in the area must obey boundary signs and be aware that something could fall on or near them without warning.  

Everyone inside the work area must wear appropriate Personal Protective Equipment (PPE).  

Existing conditions where elevated work takes place should be evaluated before work starts to ensure barriers such as toeboards or tool-catching netting is in place. For example, toeboards or screens can be used to close the space above the floor of a scaffold so tools do not inadvertently drop off, and debris nets can be used to catches tools or materials. 
Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only. 

The following recommendations are provided to prevent injury from objects falling into a normally occupied space.

�	Post the entry to the work area with a warning of the particular hazard (e.g., Overhead Work).
�	Prevent entrance of nonessential personnel by establishing barricades, roping off the area with appropriate signage, and/or positioning spotters.
�	Allow only employees actively involved in work inside the barricade.
�	Ensure that tools are tethered while in use at elevated positions and secured inside a tool bucket or pouch when not in use.
�	Walk down all work steps with an eye to where and when objects could fall.
�	Periodically inspect areas subject to vibrations from water, high winds, or motors.
�	Where it is difficult or impossible to ensure the safety of workers below, reschedule the work to be performed off-shift or at night.
�	Inspect barriers or scaffolds with a questioning attitude: "What is the smallest item that can fall through that opening?"
�	Perform Extent of Condition reviews to determine if similar conditions exist in other areas or buildings. 
JLab Preventive Measures 
Jefferson Lab requires individuals who work at elevations to be trained on the particular mode of elevation.  Training includes:  SAF307 Ladder Safety; SAF303A Baker Scaffolding; SAF303B Tube and Coupler Scaffolding; SAF303C Tubular Welded Frame Scaffolding; SAF302 Aerial Manlift.  All elevated work training includes fall and drop prevention methods. 
Comments 
1/6/2015 9:44:09 AM by Bailey, Mary Jo 
Submitted to those who are trained to work at elevations. 
	
Summary 	Lesson ID: 	867 
	Status: 	OK 
	Doc ID: 	2015-JLAB-867 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	1/6/2015 9:39:08 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	1/6/2015 9:44:09 AM 
	Source: 	DOECRD 
	Location: 	OTHER 
	Cost Savings: 	
	Contact: 	Direct questions to Ashley Ruocco at 301-903-7010 or ashley.ruocco at hg.doe.gov 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	2 times Attachments 

    * OE-3_2014-07 Falling Objects.pdf 
Hazard Issues 

    * Working at Elevations 
Skills 

    * SAF302: AERIAL PLATFORM/MANLIFT OPERATION 
    * SAF303: SCAFFOLD SAFETY 
    * SAF307: LADDER SAFETY 
Distribution/Notification 

    * *Division Safety Officers (DSOs) 
    * *Safety Wardens 
    * *DOE Notification 
    * *ESH&Q Liaisons 




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