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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=962">Inadequate LOTO Results in Hand Injuriy- Idaho National Laboratory</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>This event emphasizes the importance of identifying all hazards of an activity and determining the optimum safe method(s) to isolate, mitigate or appropriately control those hazards. This is particularly important when working with a combination of hazardous energy (electrical) and moving parts (mechanical), or any combination of the two.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On June 15, 2016, a subcontract mechanic was performing preventive maintenance on an air handler. The worker had isolated the fan's electrical power through a simple Lockout/Tagout (LO/TO) of the variable frequency drive (VFD) and observed the fan slow to a stop. While attempting to remove the belt guard, the mechanic placed his hand on the belt system to brace himself. Because of the pressure, the fan started to rotate and the worker's hand was pulled in between the belt and the pulley system.
The resulting injury consisted of trauma to the right hand including a broken bone in the ring finger.
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<h2 style="white-space:nowrap">Analysis</h2>
<pre>The LO/TO isolated only the electrical energy for the fan and did not address the potential hazard of unexpected movement, in this case, from pressure differential or draft through the area.</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.
The worker manually reversed the belt to release his hand and reported his injury to his co-worker, who notified the supervisor. The supervisor called 911 and Facilities and Site Services management.
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<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab has a robust hazard identification process imbedded within its work planning tools (e.g. ATLis, and similar). These processes are supported by ES&H Manual Chapter 3210 Work Planning, Control, and Authorization Process.
As part of its Lock, Tag, Try (LTT) Processes (outlined within ES&H Manual Chapter 6110 Appendix T1 Lock, Tag, Try Procedure) Jefferson Lab considers multiple energy sources during every LTT. This step is so important that it is included as a separate process step to be performed prior to commencement of work.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/2/2016 7:43:17 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those with SAF603A: ELECTRICAL SAFETY AWARENESS</pre>
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<legend>Summary</legend>
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<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">962</td>
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<tr class="row">
<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-962</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Best Practice</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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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">9/2/2016 7:34:32 AM</td>
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<tr class="row">
<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">9/2/2016 7:43:17 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
DOECRD
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<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">INL</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">Dwight Stevenson, Idaho National Laboratory 208-526-2840</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>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=4537">DOE - Fan.pdf</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4538">ES&H Manual Chapter 6110 Appendix T1 Lock, Tag, Try (LTT) Procedure</a></li>
<li><a target="_blank" href="downloadAttachment?attachmentId=4539">ES&H Manual Chapter 3210 Work Planning, Control, and Authorization Process</a></li>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Electricity</li>
<li>Lock, Tag, Try</li>
<li>Pinch Points</li>
<li>Stored Energy: Mechanical, Hydraulic, Pneumatic</li>
</ul>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF603A: ELECTRICAL SAFETY AWARENESS</li>
</ul>
</fieldset>
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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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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>.