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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=831">Severe Injuries Occurred while Moving Excess Property – Oak Ridge National Laboratory (ORNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>For a copy of the original report, see Attachments on Lessons Learned page.
In this event, a worker was severely injured while performing a material handling task. Causes include missed opportunities to effectively use work processes, lack of communication of previous issues, and inadequate recognition of risks led to legacy hazards being passed down to employees.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On March 31, 2014, two salvage workers were moving a 65-inches tall (including the stand and wheels), 1,585 lb scattering chamber (see attached photos) - one behind, the other in front. When the stand’s lead wheels stopped at the transition between the loading ramp and the truck bed, the chamber tipped over onto the front worker, pinning him underneath.
This same chamber had tipped over in the delivery truck during transport. The “excess property form” had been updated to indicate that the chamber was "top heavy" and that riggers were needed to move it; however, this form was not read by the salvage workers.
The salvage workers were not aware of the chamber’s weight, but the presence of the wheels led them to conclude that rolling it was acceptable. The fact that the ground surfaces were level contributed to this assumption. They did not recognize hazards related to weight, high center of gravity, or tipping.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>The requirements for implementing ORNL work processes were not followed with sufficient rigor during this task. An inproper hazard analysis resulted in inadequate controls. The work plan had been updated for the activity and included hazards attributable to material handling, manual lifting and power tools; however, ORNL’s work processes and tools were not used.
- "Top Heavy" Hazard, noted on the Excess Property form, was not mentioned in the work planning nor the job performance procedures. This made the work plan insufficient.
- The work plan did not address the full range of hazards associated with warehouse operations (e.g., unstable loads)
- A hazard control briefing was not provided to the assigned workers.
- The primary positions, responsible for safe operations in the area ,were inexperienced and not fully cognizant of detailed procedures available to support their responsibilities. They did not follow the procedure requiring them to consult with supervisor during activities when issues or problems occur.
- Requirements for bringing in riggers for heavy loads was not adequately defined.
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<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.
Staff from within the facility responded immediately by removing the chamber from the injured employee, and rendering aid. The employee sustained fractures to his lower legs, a broken right thumb, and several lacerations.
A full investigation of the accident and activities leading up to it was conducted. This accident was determined to be preventable by the investigation team.
Numerous corrective actions have been identified. These cover a wide range of activities that include:
• Organization-specific: improve work processes between Excess Property Sales and moving crews.
• Directorate level: revise the supervisor training and management assessment programs and implement a Safety Engagement Program.
• Lab-wide: management reviews, material handling training, and senior safety culture mentor position.
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<h2>Comments</h2>
<h5 style="white-space:nowrap">7/7/2014 9:50:52 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
•SAF402: CRANE OPERATION AND RIGGING
•SAF101: Work Planning and Control Familiarization
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">831</td>
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<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2014-JLAB-831</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Info</td>
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<td class="label" nowrap>Safety Related:</td>
<td class="dataval">YES</td>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Issued:</td>
<td class="dataval">7/7/2014 9:46:00 AM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">7/7/2014 9:50:52 AM</td>
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<td class="label">Source:</td>
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DOECRD
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<td class="label" nowrap>Location:</td>
<td class="dataval">ORNL</td>
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<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
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<td class="label" nowrap>Contact:</td>
<td class="dataval">Jon Forstrom (forstromjm@ornl.gov)</td>
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<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<td class="label" nowrap>Viewings:</td>
<td class="dataval">2 times</td>
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<legend>Attachments</legend>
<a name="attachments"></a>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3140">M:\wcd\LessonsLearned\DOEOEC\DOE Lessons Learned - Material Handling10 pic.pdf</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=3141">M:\wcd\LessonsLearned\DOEOEC\DOE Lessons Learned - Material Handling10.pdf</a></li>
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<legend>Hazard Issues</legend>
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<li>Material Handling Equipment</li>
<li>Tools - Machine & Portable</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF402: CRANE OPERATION AND RIGGING</li>
<li>SAF101: Work Planning and Control Familiarization </li>
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<legend>Distribution/Notification</legend>
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<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
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