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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=921">Unmarked Crate Topples During Movement with Forklift - Argonne National Laboratory</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.
It is standard practice that at the end the work shift all remaining items be removed from the loading dock area to the nearby high bay leaving the dock clear for the start of the next shift. A skilled material handling specialist found a crate, already positioned on a forklift, causing him to believe the load was ready to be moved and could be without further precaution. As he began raising the forks, he sensed a stability problem and immediately began to lower them. As he did so the crate toppled against a nearby material handling cart and conveyor track system. There were no injuries. There was no damage to the material handling cart, nor the conveyor system. One of the particle board panels on the crate was cracked but there was no visible damage to the crate¿s contents.
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<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On June 18, 2015, a large wooden crate, measuring ten foot long by seven foot high by one and one-fourth foot wide, weighing 451 pounds, containing an outdoor metal sign, was delivered to the material receiving area. The crate was positioned inside and against the wall of the delivery truck trailer and needed to be unloaded. The Delivery Specialist contacted the Shipping/Receiving Supervisor to determine the crate's recipient; and requested a material handling and rigging team for assistance in removing it from the truck.
Three riggers arrived to unload the crate. The specialist showed them the location and left. The riggers, using a crane, positioned the crate at an angle across the forks of a forklift. One rigger operated the forklift and one rigger was positioned at each end of the crate to guide it. In this manner the crate was unloaded from the truck. The forklift, with the crate still on the forks, was placed inside the receiving dock, near the conveyor track (used for transferring normal size packages to the high bay area for processing). The riggers then left with no further incident.
The recipient was contacted by the specialist and plans for the crate to be delivered were being organized. Meanwhile the forklift and crate were left in the loading dock area.
As the workday was drawing to a close, the specialist noted that the forklift truck, with the crate, was still parked on the dock. The practice for the area was that no items be left on the dock at the end of the shift so as to leave the dock clear for the start of the next. As there was no indication that the load on the forks was not secure, the specialist commenced operation to move the crate off the dock, causing it to become unstable and fall.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>The specialist was knowledgeable in forklift truck operations, had been trained, possessed twenty years experienced, and had no record of incidents. Using his past experience he assumed that the load was stable as it was already on the forks, and that it was secure. He was not concerned about the oversize measurements of the load as it was already on the forks with no evidence of additional assistance needed to move it.
The Rigging Team abandoned the load on the dock without denoting that it was unstable, that additional assistance would be required to relocate it; nor did they attempting to secure it.
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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.
The Specialist was required to attend refresher training in accordance with OSHA 1910.178, Powered Industrial Trucks "... refresher training is required when an operator is involved in an accident. The employee shall be refreshed in operation of the forklift truck used in the event and in the securing or obtaining assistance when lifting and moving unusual-sized crates."
Revision were made to Laboratory Management System Procedure 262, General Receiving Operations, to provide direction with the use of Hold Tags for non-conforming items. This revision formalized the interim directions provided.
All material handling specialists were trained on the use of Hold Tags following the release of Laboratory Management System Procedure 262, General Receiving Operations.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab has an extensive vetting process for material handling equipment use which includes both training and engineered safeguards. Upon completion of a task, a qualified operator must return the material handling equipment's key back to the appropriate key box or group leader. Failure to do so results in disciplinary action in accordance with Administrative Manual - 212 Voluntary and Involuntary Separations. Thus, a forklift would not be "abandoned" with a load on the forks, stable or otherwise.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">11/23/2015 11:11:54 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in
SAF502: FORKLIFT OPERATOR TRAINING</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">921</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">2015-JLAB-921</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">11/23/2015 11:05:00 AM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">11/23/2015 11:11:54 AM</td>
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<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
DOECRD
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<td class="label" nowrap>Location:</td>
<td class="dataval">ANL</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">Michael Sodaro, msodaro@anl.gov, (630) 252-8525</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">1 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=4202">DOE - Crate Pic.pdf</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4203">DOE - Crate.pdf</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Material Handling Equipment</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF502: FORKLIFT OPERATOR</li>
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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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