<!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=916">Stair Treads in Aging Facilities Can Dislodge Suddenly Creating Slip/Trip Hazards - Y-12 Production Site</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.
Stair tread adhesive failure is not readily evident when it occurs. This creates a potential trip/slip hazard that is unknown to personnel who utilize the stairs. Inspection and repair activities need to consider the age and condition of all treads on a set of stairs. When indications of failure are noted, similar treads should be replaced before they fail.
</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>A maintenance planner was descending a set of stairs when one of the rubber tread coverings came completely loose and slid, causing him to lose his footing and fall approximately 10 feet down the stairs. The planner was holding the stair railing with his left hand when he lost his footing. He tried to arrest the fall by gripping the railing tightly. The loose tread remained in one piece and the planner "rode" the tread as he fell to the bottom of the stairs. After the fall, the planner experienced pain in his left shoulder and knee.
Aging facilities present special problems for items that do not require periodic maintenance. Stair tread covers and the adhesives used to anchor them are considered "permanent" and are not normally maintained or replaced at a set interval. The need to replace tread covers is normally performed when indications of wear or physical damage is evident. For the stairs associated with this event, several of the tread covers had previously been replaced and one was missing pending future replacement.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The adhesive that anchored the tread cover to the metal stair had deteriorated with age. The portion that still secured the tread released suddenly when the planner transferred his weight to it. </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.
Immediate Actions:
The maintenance planner was seen by site medical personnel then sent to an off-site physician. The physician ordered a diagnostic for a shoulder strain, prescribed pain medication, and referred the planner to a shoulder specialist for additional review where it was confirmed that surgery would be required. The planner was released back to work with physical restrictions pending surgery and recovery.
Additional Actions:
A maintenance activity review was performed on requests for replace or repair of damaged stair treads/covers across the site. It was found that 47 work requests had been generated to repair or replace deficient stair treads/covers since 01/30/2006. Based on the variety of locations and the number of work requests, there was no single area that indicated unusual frequency.
Discussed with personnel who perform the site-wide Facility Condition Assessment Survey (FCAS) to confirm that stair treads are part of the survey. They confirmed that tread covers are reviewed during these surveys and those found damaged, lose or missing are reported and repaired/replaced immediately.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab¿s Safety Warden Program (ES&H Manual Chapter 2500 Safety Warden Program) includes weekly, monthly, and quarterly area inspections. These are performed by Safety Wardens who are selected because they know the hazards associated with their assigned areas, and perform the majority of their work in those areas. Facility Management Work Requests are submitted for any hazard (including stair tread maintenance) when appropriate.</pre>
</div>
<div id="comments_div">
<a name="comments"></a>
<h2>Comments</h2>
<h5 style="white-space:nowrap">10/19/2015 1:48:03 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those with Ladder Safety Training</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">916</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">2015-JLAB-916</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">10/19/2015 1:43:57 PM</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">10/19/2015 1:48:03 PM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
DOECRD
</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">Don Taylor, 865-574-0507</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">1 times</td>
</tr>
</table>
</fieldset>
<fieldset>
<legend>Attachments</legend>
<a name="attachments"></a>
<ul class="lesson_attribute_listing">
</ul>
</fieldset>
<fieldset>
<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Ergonomics - Lifting, Carrying, Repetitive Motion</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF307: LADDER SAFETY</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>
<br>
<br>
Do you have a lesson learned you would like to contribute? Contact the <a href="mailto:mbailey@jlab.org,sjsmith@jlab.org,cjohnson@jlab.org">Lesson Learned Coordinator</a>.