<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html>
<head>
<title>Jefferson Lab Lessons Learned : Print Lesson</title>
<base href='https://misportal.jlab.org/ll/'>
<!--[if IE]>
<style type="text/css">
#page_content input[type=checkbox], #page_content input[type=radio] {
background-color: transparent;
border: 0;
}
</style>
<![endif]-->
</head>
<body>
<div id="doc3" class="yui-t7">
<div class='round' id='pageMessages'>
<!-- -->
</div>
<div id="lesson" class="yui-gc">
<style type="text/css">
pre {
white-space: -moz-pre-wrap;
white-space: -pre-wrap;
white-space: -o-pre-wrap;
white-space: pre-wrap;
word-wrap: break-word;
overflow: hidden;
margin-left: 10px;
}
</style>
<div id="topbar">
<div id="lesson_title">
<table width="100%">
<tr>
<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=822">Non Implementation of Corrective Actions Identified during Injury investigation prompted a Letter of Concern from the Department of Energy (DOE) Office of Enforcement and Oversight – Savannah River Remediation, LLC (SRR) </a></td>
</tr>
</table>
</div>
</div>
<table width="100%">
<tr>
<td valign="top" width="100%">
<div id="maintextcol" class="yui-u first">
<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>For a copy of the original report, see Attachments on Lessons Learned page.
A SRR worker suffered a tear of the left shoulder rotator cuff, which required surgery and 75 days from work. DOE “…found that SRR did not adequately identify and abate the hazards of lifting the check valve during planning, approval, and performance of the work, including considering whether the American Conference of Governmental Industrial Hygienists weight limits were applicable. DOE’s evaluation of the circumstances associated with this event disclosed potential violations of 10 CFR 851 and its invoked standards in the areas of ergonomics hazard assessment and identification and implementation of hazard controls.” (See attachment for further details.)
</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On March 25, 2013, workers were assigned to replace a check valve. Work planning identified the weight of the valve to be approximately 40 lbs. This weight is under the SRR control limit which, according to the ergonomic program in place, would trigger either ergonomic guidance by Industrial Hygiene (IH), or require mechanical assistance to mitigate the lifting hazards. The identified weight left assessment of the lift up to the workers and their supervisor. At the time there was no viable means to confirm the actual weight of the valve, so the weight was accepted as defined in the work plan. (The event investigation determined that the actual weight of the valve was 81lbs).
The work planning process in place at the time of the event did not effectively identify all the potential hazards associated with manual lifts. As an example the worker’s planning process did not adequately invoke IH to evaluate lifting hazards even when it did reach SRR levels. Also there was no clear link between an activity’s hazard analysis process and the ergonomics program in place.
Other unidentified lifting hazards found during the event investigation, which should have prompted an IH evaluation included:
• Task required at least eight lifts to complete, including removing the old valve and replacing it with the new unit. The work plan only identified a single lift.
• At least one lift was from floor level to a transport cart 26-inches high. Lifts from the floor are considered the most strenuous for workers.
• At least one lift required carrying the check valve ~20-feet. This aspect added additional stress on the workers shoulder.
• At least one lift required a single worker to support the entire weight of the check valve while others inserted mounting bolts.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The investigation identified three corrective action recommendations:
1. Find/purchase a jack applicable to the load and workspace;
2. Construct a support for a chain hoist; and
3. Research weights during the planning process and indicate same in work documents.
As of April 10, 2014 only one of the three actions had been implemented prompting the DOE Office of Enforcement and Oversight to issue a letter of concern to SRR.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Below are the consequences of the above event. They are provided for information and discussion purposes only.
• Appropriately apply American Conference of Governmental Industrial Hygienists lifting requirements and implement provision for compliance into the SRR Ergonomic Program.
• Adequately follow-up on actions recommended during the investigation to avoid event recurrence.
• Consider the information contained in the Letter of Concern as a means to improve worker safety and health to reduce potential for future injuries.
</pre>
</div>
<div id="comments_div">
<a name="comments"></a>
<h2>Comments</h2>
<h5 style="white-space:nowrap">5/13/2014 10:37:11 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those with the following current training:
•SAF502: FORKLIFT OPERATOR
•MED05: SAFE LIFTING (ERGONOMICS)
</pre>
</div>
</td>
<td valign="top">
<div class="yui-u">
<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">822</td>
</tr>
<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
</tr>
<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2014-JLAB-822</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
</tr>
<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">YES</td>
</tr>
<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">5/13/2014 10:31:09 AM</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">5/13/2014 10:37:11 AM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
OTHER
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">OTHER</td>
</tr>
<tr class="row">
<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
</tr>
<tr class="row">
<td class="label" nowrap>Contact:</td>
<td class="dataval">Mr. Kenneth Rueter, Project Manager</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">2 times</td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3044">M:\wcd\LessonsLearned\Ergonomic\Valve Check Lift.pdf</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=3045">M:\wcd\LessonsLearned\Ergonomic\Valve Check Lift File-DOELL.pdf</a></li>
</ul>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Material Handling Equipment</li>
<li>Other: Safety Document Review</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF502: FORKLIFT OPERATOR</li>
<li>MED05: SAFE LIFTING (ERGONOMICS)</li>
</ul>
</fieldset>
<fieldset>
<legend>Distribution/Notification</legend>
<ul class="lesson_attribute_listing">
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
</ul>
</fieldset>
<!--
<fieldset>
<legend>Applicable Orgs</legend>
<ul class="lesson_attribute_listing">
</ul>
</fieldset>
-->
</div>
</td>
</tr>
</table>
<script language="javascript">
var commentTextarea = document.getElementById("commentForm:commentText");
if (commentTextarea){
var validationErrorFound = commentTextarea.parentNode.innerHTML.indexOf("Validation Error: Value is required.") > -1;
if (validationErrorFound){
// add hash if necessary
if (window.location.hash == null || window.location.hash == "" || window.location.hash == "#"){
window.location.hash = "#comments";
}
}
else {
//JSF likes to hold on to the values entered into the form...so blank them out
commentTextarea.value = "";
commentTextarea.form.elements["commentForm:commentType"].selectedIndex = 0;
var numStars = commentTextarea.form.elements["commentForm:stars"].length;
for (var ii=0; ii<numStars; ii++){
commentTextarea.form.elements["commentForm:stars"][ii].checked = false;
}
}
}
</script>
</script>
</div>
<br>
<br>
</div>
</body>
</html>