[Hallb-engineering] Fwd: Lesson Learned "Analyze and Respond to Hazards at the Task Level for All Tasks Being Performed - Lawrence Livermore National Security, LLC "

Douglas Tilles tilles at jlab.org
Mon Mar 2 11:18:13 EST 2015

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Subject: Lesson Learned "Analyze and Respond to Hazards at the Task Level for All Tasks Being Performed - Lawrence Livermore National Security, LLC "

Jefferson Lab Lessons Learned : Print Lesson 
	Analyze and Respond to Hazards at the Task Level for All Tasks Being Performed - Lawrence Livermore National Security, LLC 
Statement of Lessons Learned 
For a copy of the original report, see �Attachments� on Lessons Learned page. 

Complete work by performing the different tasks at the right time and in the right way. Analyzing and responding to each task�s hazards helps maintain safety. This helps identify when multi-tasking is acceptable and when it is not. 
Discussion of Activities 
A worker was inspecting a thin-walled glass tube approximately 2.5-inches in diameter by 32-inches long in a compact workspace.  The tube had been retrieved from a scrap glass tube storage area and broken edges indicated that some portion of the tube was damaged. The worker was seeking a location on the tube where sound glass could be found.

At the same time he was monitoring a glass-cutting saw and was listening to ensure continuing progress of that work.  The worker was not wearing cut-resistant gloves, consistent with glass work fabrication practices.

Upon hearing an unusual noise from the saw, the worker turned to check. As he did, the tube he was inspecting tapped the workbench and shattered, cutting the lower portion of his fifth (little) finger on the right hand. 
Two different tasks, inspecting and sawing, were being performed and safety practices applicable to one were not compatible with the other. A thorough hazards analysis was needed for each: 

�	hazards associated with handling and inspecting a 32-inch long piece of glass in a compact space.

�	hazards associated with handling and inspecting damaged glass with sharp ends. 

�	ability to "feel" the tension of the glass as part of the cutting operation.  Gloves inhibit this skill. 
Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only. 

A work supervisor in a nearby lab heard the glass break, and immediately assisted the worker, summoned appropriate medical response, preserved the scene, and implemented other actions.

A thorough evaluation of each task was performed to identify conditions and hazards needing to be mitigated. 

�	Use new, undamaged, shorter material more compatible to the area and easier to handle.

�	Perform the inspection in a location where there is adequate handling space.

�	Use personal protective equipment appropriate for each task. Wearing cut-resistant gloves while handling and inspecting sharps.  

�	If PPE difference cannot be reconciled, the two tasks are better done in series than in parallel. 
JLab Preventive Measures 
Within Jefferson Lab�s Work Planning, Control, and Authorization Process, it is within the authority of every worker to analyze the hazards of a task being performed.  This is not just done at the planning level, but also when the work is actually being performed.  All workers have the responsibility to suspend work to improve hazard mitigation techniques. 
3/2/2015 8:57:25 AM by Bailey, Mary Jo 
Submitted to those who perform Work Safety Observations. 
Summary 	Lesson ID: 	877 
	Status: 	OK 
	Doc ID: 	2015-JLAB-877 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	3/2/2015 8:51:46 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	3/2/2015 8:57:25 AM 
	Source: 	DOECRD 
	Location: 	LANL 
	Cost Savings: 	
	Contact: 	Jeff Horning, horning1 at llnl.gov, 925-424-5393 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

    * DOE - Yellow - Analyze Hazards.pdf 
Hazard Issues 

    * Chemicals 
    * Personal Protective Equipment 
    * Tools - Machine & Portable 

    * SAF120kd: SAFETY OBSERVATION PROGRAM Read (http://www.jlab.org/ehs/ehsmanual/manual/3700.html) Then Contact Bob May ext.7632 to arrange practical 

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

Do you have a lesson learned you would like to contribute? Contact the Lesson Learned Coordinator .

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