[Hallb-engineering] Fwd: Lesson Learned "Set Up Work to Avoid Line-of-Fire Incidents - Worker Struck by Crowbar-Lawrence Livermore National Security, LLC"

[Douglas Tilles]

FYI

----- Forwarded Message -----
From: "mbailey" <mbailey at jlab.org>
To: "mbailey" <mbailey at jlab.org>
Sent: Monday, October 17, 2016 10:00:12 AM
Subject: Lesson Learned "Set Up Work to Avoid Line-of-Fire Incidents - Worker Struck by Crowbar-Lawrence Livermore National Security, LLC"

Jefferson Lab Lessons Learned : Print Lesson 
	Set Up Work to Avoid Line-of-Fire Incidents - Worker Struck by Crowbar-Lawrence Livermore National Security, LLC 
	
Statement of Lessons Learned 
Using the correct tools and setting the work up properly can be the difference in safety and success. 
Discussion of Activities 
A pneumatic nail gun did not fully seat a nail, leaving the nail head protruding from the wood surface surrounding it. The worker attempted to hammer the nail into place, but it bent.  Several attempts to remove the nail with a 12-inch crowbar were unsuccessful.  The worker then switched to use a 24-inch crowbar.  When the worker pulled the free end of crowbar toward himself, the nail head deformed causing the crowbar to suddenly, and unexpectedly, slip off the nail striking the worker in the forehead. This resulted in a small laceration and some swelling. 
Analysis 
After the 12-inch crowbar failed to remove the nail, the worker used a 24-inch crowbar. As Attachment 1 shows, the free end of the 24-inch crowbar was pulled toward the worker.  This placed him in the path of the free end.  The straight claw at the free end was uncomfortable to grip, so the worker grasped the crowbar just below it. This left the straight claw�s sharp edge exposed. The elevation of the workpiece and the direction of the work made the employee�s head and shoulders particularly susceptible to being struck if the nail were to come out of the wood suddenly or if the crowbar lost its grip on the nail. 

The assumption was that the greater force applied by the 24-inch crowbar would remove the nail. Focused on removing the nail, the worker did not consider the possibility that the greater force could distort the nail head (See Attachment).   

NOTE: The nail was later removed by using a cat�s paw tool (see Recommended Actions). 
Recommended Actions 
The worker immediately went to the washroom to assess the injury and clean his wound. His coworker notified the supervisor who escorted the worker to Health Services for treatment.  

LLNL�s Carpenter Shop recommends not using a crowbar to remove nails. A crowbar is better suited for disassembly and demolition work.

Tools that are better suited to nail removal include the claw on a hammer or a device designed to grip the nail shaft, such as a cat�s paw, flat bar, bull nose plier, diagonal plier or alternate gripping tool. (See Attachment)

When an attempt to perform a task is unsuccessful, it is a good idea to stop the work and evaluate the situation. Identify alternative approaches, the potential hazards introduced by each, and the preventive/mitigating actions needed to ensure safe completion of the operation. 
JLab Preventive Measures 
Jefferson Lab offers Ergonomic Consultations for any work process.  Call Occupational Medicine x7539 to set up an appointment. 
Comments 
10/17/2016 8:33:11 AM by Bailey, Mary Jo 
Submitted to Forklift Operators 
	
Summary 	Lesson ID: 	973 
	Status: 	OK 
	Doc ID: 	2016-JLAB-973 
	Priority: 	Info 
	Safety Related: 	YES 
	Originator: 	Bailey, Mary Jo 
	Issued: 	10/17/2016 8:30:39 AM 
	Approved By: 	Bailey, Mary Jo 
	Approved On: 	10/17/2016 8:33:11 AM 
	Source: 	DOECRD 
	Location: 	LANL 
	Cost Savings: 	
	Contact: 	Joe King, king39 at llnl.gov, 925-423-0463 
	Queued Emails: 	0 
	Sent Emails: 	0 
	Viewings: 	1 times Attachments 

    * DOE - Crowbar.pdf 

Hazard Issues 

    * Portable Hand Tools 
    * Sharp Edges 
Skills 

    * SAF502: FORKLIFT OPERATOR 
Distribution/Notification 

    * *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 .