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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=931">ENG-16-0104 Employee Injures Left Shoulder While Descending a Ladder</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Even when a task seems simple, maintain your situational awareness until that task is completed. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On January 4, 2016 around 8:00 pm, an employee was using a step ladder to access a valve located on the top of cold box to start the cool down process. The valve need to be turned one half of a turn to do so. The employee visually inspected the step ladder and did not identify any hazards.
The employee ascended the step ladder and turned the valve without incident. Upon descent of the step ladder, the employee misjudged the distance to the ground and began to fall. His body¿s natural reaction of tensing up occurred and while his left hand maintained his grip on the handle of the cold box, his left shoulder absorbed the employee¿s full body weight.
The Employee heard a pop. He went home and immediately called his supervisor. He reported to Occupational Medicine the following morning where he was referred off-site for evaluation. The employee was later diagnosed with a torn rotator cuff. The employee returned to work with no use of left arm until cleared by a physician.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause: Mental lapse while descending the ladder. It appears that the employee was not fully invested in the task of descending the ladder and therefore misjudged his footing. </pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>All- Staff email to the Lab reminding them that maintaining situation awareness while completing a task is vital to their mission.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>None were identified during the investigation of this event.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">2/16/2016 2:16:42 PM by Johnson, Tina</h5>
<pre>SME reviewed and approved. Please share this lesson learned within your work groups. This is also one that will be helpful at home as well.
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">931</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">2016-JLAB-931</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">NO</td>
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<td class="label" nowrap>Originator:</td>
<td class="dataval">Johnson, Tina</td>
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<td class="label" nowrap>Issued:</td>
<td class="dataval">2/10/2016 3:07:16 PM</td>
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<td class="label" nowrap>Approved By:</td>
<td class="dataval">Johnson, Tina</td>
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<td class="label" nowrap>Approved On:</td>
<td class="dataval">2/16/2016 2:16:42 PM</td>
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<td class="label">Source:</td>
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<a href="https://www.jlab.org/div_dept/dir_off/oa/notable/secure/Eng-16-0104.pdf" target="_blank">TJNAF NE</a>
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<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</td>
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<td class="label" nowrap>Cost Savings:</td>
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<td class="label" nowrap>Contact:</td>
<td class="dataval">Tina Johnson</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">7 times</td>
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<legend>Hazard Issues</legend>
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<li>Other: Ladder Safety </li>
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<legend>Skills</legend>
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<li>SAF307: LADDER SAFETY</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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