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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=862">Multiple Factors Contributed to Hand Injury During Chiller Move - Lawrence Livermore National Security, LLC</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.
A subcontract employee’s hand was injured while moving a Trane chiller, weighing approximately 26,000 pounds, from the inside of a storage tent to a staging platform just outside its south wall.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>The chiller’s feet, one at each corner, rested on four 10,000-pound capacity Hilman steel chain rollers. An elastomeric pad was between each roller and foot; no rollers were bolted or clamped to the chiller; one or more rollers were affixed by cargo straps. At the start of the move, all rollers rested on plates on top of a level asphalt surface. The rollers at the leading end were on a double layer of ¼-inch thick aluminum plates, and the rollers at the trailing end rested on a 3/8-inch thick carbon steel plate that extended to just short of the leading end’s rollers.
During the move, there were several instances when the rollers slipped. When this happened, personnel stopped movement and re-adjusted the roller. When the roller at the northeast corner of the chiller departed the double layer of ¼-inch thick aluminum plates, it stopped moving. The subcontract workers stopped movement in order to raise that corner of the chiller and adjust the roller using two 5-ton toe jacks. The worker happened to place his hand on the top of one of the jacks during a coordinated lift. The chiller slipped forward, causing the jack to tilt toward the chiller and pinch the worker’s hand between the top of the jack and the top inside surface of the flange.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Riggers qualified to OSHA and national consensus standards per DOE-STD-1090-2011 (e.g., LLNL’s MUSD riggers) were not involved in the planning or execution of this work.
Proper performance of the move should have involved properly attaching proper capacity rollers.
The staging platform was improperly constructed. Sand, which cannot be compacted, was used instead of an aggregate base. A required 1-inch thick steel plate, was substituted with cobbled together ½ to ¼ inch plates. The final plate configuration allowed the weight at the chiller’s corner to push one plate into the sand and indent another. The distortion prevented the roller from moving onto the second plate.
When movement stopped the rollers were not blocked, this allowed movement during the jacking operation.
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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.
1. Ensure qualified personnel are involved in all stages of planning and execution.
2. Ensure a well-defined work scope is documented and hazards and controls are clearly identified at the task level for non-routine and high-risk work as well as routine work.
3. Ensure proper identification and communication of hazards and controls.
4. Ensure increased safety oversight is available for non-routine and high-risk work.
5. Encourage a questioning attitude.
6. Ensure consistent definition of roles and responsibilities in authorizing documents and work control field work packages.
7. Ensure that field work packages meet LLNL work control requirements.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab has robust and effective work control requirements. Use of Operational Safety Procedures (OSP), which requires review by Subject Matter Experts and all affected workers; is standard practice. Review of subcontractor safety work plans, drawings and technical specifications by Subject Matter Experts, has been incorporated effectively within the ESH&Q Document Review Database. Comments and issued are addressed and incorporated into the work plans as appropriate. Safety professionals also monitor and assess subcontractor’s performance during work to ensure compliance with safety issues.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">11/17/2014 9:39:58 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
•SAF402-1: CRANE OPERATOR TRAINING
•SAF120kd: SAFETY OBSERVATION PROCEDURE
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">862</td>
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<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
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<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2014-JLAB-862</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">11/17/2014 9:38:59 AM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">11/17/2014 9:39:58 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
DOECRD
</td>
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<td class="label" nowrap>Location:</td>
<td class="dataval">LANL</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">Jeff Horning, 925-424-5393, horning1@llnl.gov</td>
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<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">0</td>
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<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">2 times</td>
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<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=3501">M:\wcd\LessonsLearned\Ergonomic\DOE - Yellow - Hand Injury.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Material Handling Equipment</li>
<li>Subcontracts</li>
<li>Lifting/Moving Objects</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF402-1: CRANE OPERATOR TRAINING</li>
<li>SAF120kd: SAFETY OBSERVATION PROCEDURE</li>
</ul>
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<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>
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