[Hallb-engineering] Fwd: Lesson Learned "Unexpected Personal Contact with Reflected Laser Beam, Los Alamos National Laboratory"

Douglas Tilles tilles at jlab.org
Tue Apr 12 06:06:51 EDT 2016

----- Forwarded Message -----
From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Monday, April 11, 2016 3:00:16 PM
Subject: Lesson Learned "Unexpected Personal Contact with Reflected Laser Beam, Los Alamos National Laboratory"

Jefferson Lab Lessons Learned : Print Lesson 
	Unexpected Personal Contact with Reflected Laser Beam, Los Alamos National Laboratory 
Statement of Lessons Learned 
Communication among workers in a multi-user lab is important to ensure everyone understands the hazards in the area and appropriate mitigation techniques for each.


Ensure that the correct material is being used for hazard control.  Use of inappropriate material can lead to unexpected hazards and off-normal conditions.

Reconfigure workplace conditions and supply appropriate tools to allow workers to perform required task without difficulty. 
Discussion of Activities 
On November 19, 2015, while working in a laser lab at the Sandia National Laboratory Center for Integrated Nanotechnologies (CINT), a Los Alamos National Laboratory (LANL) employee received an eye injury from a reflected, non-visible laser beam. 
The laser (Class 4, pulsed, wavelength 800 nanometer) was configured to split its beam to two work areas so qualified operators could conduct simultaneous research experiments.  When this incident occurred the laser output beam was being projected to both work areas although only one area was actively being used at the time.  The beam directed to the second area was being blocked by an optically opaque material.


The employee was wearing the required laser eye-wear while using an infrared laser viewing card (per procedures) to trace the experiment�s beam path.   The micrometer markings were difficult to read so the employee stepped up onto a small step ladder to get a better view and momentarily lifted his laser safety eye-wear to increase visibility.  He immediately noticed a flash of light in his left eye so quickly replaced the eye-wear.


The employee did not immediately think he had sustained any injury from the flash and used an infrared viewer to locate its source.  He discovered that the portion of the laser beam being directed to the second work area, instead of being blocked by the opaque material was actually being reflected off it.  The opaque material was positioned at an inclined angle slightly off-vertical causing the beam to reflect at an upward angle toward the area where the employee had been standing on the step ladder.  The opaque material had been placed there by another LANL operator who had been conducting experiments in the adjacent work area several days before. 
Recommended Actions 
Below are the consequences of the above event.  They are provided for information and discussion purposes only.


Later that day the employee noticed a blurry spot in the vision of his left eye.  He notified his supervisor the next morning, and was taken to Sandia National Laboratories (SNL) medical facility for evaluation.  The SNL medical facility did not find any abnormalities, but referred the operator to a local ophthalmologist for further evaluation.  The ophthalmologist identified a small spot of inflammation near the fovea on the retina in his left eye and was optimistic that the spot would heal on its own. A follow-up visit was scheduled. The employee was released back to work without restrictions.


Once the stray beam was identified, a card was placed in front of the reflected beam to shield the stray reflection.


Information about the event and lessons learned were disseminated broadly to laser workers and other groups around the Laboratory.


White boards were installed at lab entrances to denote current experiment status. 


Special activities (laser alignment, etc.) are to be agreed upon in advance at team meeting, email list, and the white boards, etc., with activity and effective dates.


Laser/setup operator is responsible for terminating unused beams at point of propagation and checking/blocking stray reflections after modifying beam path. All authorized operators will be encouraged to perform pre-laboratory inspections (Inspect NHZ with IR viewer, configuration of optical table and status of lasers). (Implemented through IWDs.)

Procure and use appropriate laser beam control devices (non-reflective beam blocks appropriate for wavelength and power of laser should be placed vertically).


Ensure proper task lighting for every setup to assist with low visibility tasks.

Ensure that it is understood that under no circumstances is protective eye wear to be removed during laser operations, even if the equipment manual suggest removing eye wear to check for laser propagation/spectrum during alignment. 
JLab Preventive Measures 
Jefferson Lab requires all lasers above class 2 be covered by a Laser Operational Safety Procedure (LOSP), which restrics its use to those who have appropriately reviewed the document and been approved by the owner.  LOSPs are reviewed by Jefferson Lab's Subject Matter Expert and safety configurations are strictly enforced. 
4/11/2016 2:06:26 PM by Bailey, Mary Jo 
Submitted to those current in SAF114I: LASER SAFETY FOR INCIDENTAL WORKERS
Summary 	Lesson ID: 	942 
	Status: 	OK 
	Doc ID: 	2016-JLAB-942 
	Priority: 	Caution 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	4/11/2016 2:01:37 PM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	4/11/2016 2:06:26 PM 
	Source: 	DOECRD 
	Location: 	LANL 
	Cost Savings: 	
	Contact: 	Quanxi Jia, qxjia at lanl.gov, 505-667-2716 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	3 times Attachments 

    * DOE - Communication Pics.pdf 
    * DOE - Communication.pdf 

Hazard Issues 

    * Lasers Class 3B or 4 (Ultraviolet, Infrared, and Visible Light) 


    * *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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