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valign="top">Lesson Learned "FML-19-0920 Sprained Thumb While Intalling a Motor Lead- Recordable"</td>
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valign="top"><strong><span
style="font-size: 18px">INTERNAL MEMO</span></strong></td>
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valign="top"><span style="font-size: 14px">
<strong>December 13, 2019</strong><br>
<strong>Sent on behalf of ESH&Q</strong><br>
<strong>SUBJECT:</strong> Lesson Learned "FML-19-0920 Sprained Thumb While Intalling a Motor Lead- Recordable"<br>
<strong>CONTACT:</strong> mbailey@jlab.org
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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1121">FML-19-0920 Sprained Thumb While Intalling a Motor Lead- Recordable</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>1. When planning work and during the pre-job briefing consider potential ergonomic hazards such as poor positioning, forceful gripping, lack of mechanical tools, and task rotation.
2. When ergonomic challenges are faced in the field, halt the work and re-assess the situation. This could be as simple as discussing and implementing suggestion(s) from another co-worker.
3. When purchasing off-the-shelf materials assess potential obstacles to installation, such as size, to ensure the best equipment is purchased for the space allotted.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>An employee sprained their right thumb while installing motor leads in the CTF. The employee was placed on restrictions that impacted their ability to perform their routine job functions.</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Judgement of Need(s):
1. Management should utilize the quality assurance process when accepting equipment for which their group will be responsible for the management of repairs.
2. Management should evaluate the need for an industrial ergonomic evaluation in their regular work plans.
Root Cause:
Equipment was less then adequate - the motor's leads were shorter than "normal." This made them extremely difficult to grip during installation activities .
Contributing Cause(s):
Ergonomics Less than adequate - There was no tool available that would fit into the tight confined space without causing damage to the leads. In an effort to complete the task the employee chose to used their hands, which required forceful gripping, as that was the only thing available that would fit. </pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>1. In the future, the process vacuum (Kinney) pump motor in the CTF will be shipped to a vendor for repair. Include on the next repair order "Increase the length of the leads," to prevent recurrence of the situation. (Tag the kinney motor with this information.)
2. Dr. Chandler will conduct an ergonomics assessment of the motor and the work space.
3. The group will hold a team meeting to discuss the event and this lessons learned.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>See above corrective actions</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">12/13/2019 9:20:53 AM by Bailey, Mary Jo</h5>
<pre>submitted to those having SAF607: HAND TOOLS & LADDER SAFETY</pre>
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<legend>Summary</legend>
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<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1121</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">2019-JLAB-1121</td>
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<td class="label" nowrap>Priority:</td>
<td class="dataval">Caution</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">Bailey, Mary Jo</td>
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<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">11/15/2019 7:41:16 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">12/13/2019 9:20:53 AM</td>
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<td class="label">Source:</td>
<td class="dataval">
TJNAF NE
</td>
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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>
<td class="dataval"></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">131</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">59 times</td>
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<legend>Attachments</legend>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Ergonomics - Lifting, Carrying, Repetitive Motion</li>
<li>Machine Tools</li>
<li>Portable Hand Tools</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF607: HAND TOOLS & LADDER SAFETY</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>
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