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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1130">Abrasive Blasting Injury - Lawrence Berkeley National Laboratory (LBNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>Use a comprehensive work hazard analysis to clearly identify and define a work plan that accounts for changes in work scenario, including stopping work.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On February 12, 2020, two subcontract workers, each with a blast-hose, were performing abrasive blasting work inside Tank 82. The workers were wearing the approved personal protective equipment consisting of a cotton long sleeve shirt underneath standard long sleeve cotton overalls, along with a full face supplied air hood, earplugs, wrist length leather gloves, and steel toe boots.
After a couple of hours Worker#1 found that the deadman switch on his blast hose would not shut it off. Worker#1 exited the tank to inform the Confined Space Attendant of the issue.
Worker#1 found that the assigned Confined Space Attendant had left to get lunch for the crew and the jobsite Foreman had assumed the attendant responsibilities. Worker#1 told the Foreman of the issue. The Foreman then left Worker#1 as the Confined Space Attendant and went to the main switch to shut off the malfunctioning blast hose.
All the while Worker#2 continued working in the tank.
At some point, the malfunctioning blast hose regained pressure for a few seconds and Worker#2 was struck by abrasive material and compressed air. The injury included a laceration and tearing of his right forearm, near the elbow connection. The injured employee was hospitalized for six days and required skin graft treatments.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Based on the event investigation, the Extent of Condition (EOC) Review concluded that this incident is not indicative of a negative work performance trend or history by the subcontractor. However, the incident does demonstrate continual issues LBNL is having with subcontractor injuries due to unsafe work practices, insufficient hazard analysis and work control, and general contractors management/oversight of sub-tier contractors. In addition, there is room for improvement in LBNL processes and practices to assure that subcontractors and subcontractors are using well maintained equipment and to assure that subcontractors understand and demonstrate the appropriate and effective implementation of stop work.
It was found that the subcontractor failed in the following areas:
1. They did not implemented the full LBNL safety requirements. (i.e. they did not adequately fulfilling their safety oversight role and responsibilities, they did not ¿flow down¿ LBNL¿s safety requirements to their workers, and they did not assure that their equipment was maintained properly.)
2. They did not develop and use a comprehensive work procedure, job hazard analysis, or pre-task hazard analysis, so did not covered off-normal work conditions, including stopping work.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Establish the following for every subcontractor performing field work at LBNL:
1. Clearly defined, and identified roles and responsibilities. If key personnel are missing the work is paused until the correct and necessary crew is at full strength.
2. Require an off-normal field conditions procedure from the subcontractors. The procedure or best practices is to cover stop vs pause work scenarios.
3. Field equipment is to have, onsite, a current, reviewed, and approved, maintenance record(s). If the equipment is uncommon or unfamiliar to LBNL, a consultant may be hired to inspect the equipment before equipment is used.
4. The Project Manual/Specs is to be included with all new contracts and clearly identify the roles and responsibilities for personnel.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab assigns a Subcontracting Officer's Technical Representative (SOTR) to every subcontract. SOTRs are trained and the program requires jobsite inspections.
Confined spaces at Jefferson Lab are rigorously monitored and entry requires a Jefferson Lab Confined Space Permit. See ES&H Manual Chapter 6160 Confined Space Entry for the full program.</pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">9/2/2020 9:16:03 AM by Bailey, Mary Jo</h5>
<pre>Submitted to those with:
SAF907: Safe Entry into Confined Spaces
GEN020: SOTR QUALIFICATION</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1130</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">2020-JLAB-1130</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Caution</td>
</tr>
<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">NO</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">9/2/2020 9:10:57 AM</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">9/2/2020 9:16:03 AM</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">LBNL</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">Gabrielle Caparimo, gcaparimo@lbl.gov</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">365</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>
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<legend>Hazard Issues</legend>
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<li>Confined Space</li>
<li>Stored Energy: Mechanical, Hydraulic, Pneumatic</li>
<li>Subcontracts</li>
</ul>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF907: Safe Entry into Confined Spaces</li>
<li>GEN020: SOTR QUALIFICATION </li>
</ul>
</fieldset>
<fieldset>
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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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