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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1139">Worker Falls Through Skylight During Roofing Operations - Brookhaven National Laboratory (BNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>It is important to identify and communicate to contractors all potential hazards of a job. Many of BNL's older buildings have legacy issues. In this case the contractor, who was accustomed to working around skylights, accepted the potential risk of stepping on and breaking through, when they decided not to guard them. A questioning attitude during the work planning process and/ or during construction activities would have identified the skylights as a fall hazard to be guarded or covered prior to starting work.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Contract construction workers were using a crane to lift a roof truss into place as part of a re-roofing project. While directing the load, the signal person, who was tied off with fall protection, stepped forward to grab the tag line of the roof truss. As he walked forward to grab the tag he fell through a fiberglass skylight, approximately 6-8 feet, before his safety retractable lanyard stopped his fall. He knew there were skylight panels on the roof however, his attention was focused upward and he lost track of where he was in relation to the skylights. He was able to self-rescue, did not receive any injuries, was able to provide a statement for the incident report, and returned the next day to participate in the investigation.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Root Cause: The work planning process, at multiple stages, did not identify the hazard or address the risk posed by the skylights on a working/walking surface. The work planning activities at all levels failed to identify the skylights as a fall hazard, and when it was identified in the field, the risk posed was not properly assessed. The reviewers of the work permit, PHA's, and responsible oversight of the workers in the field failed to maintain a questioning attitude and respect for what could go wrong. The result was less than adequate mitigation.
Contributing Cause #1: The flow down of the BNL Construction Subject Area to the BNL Health and Safety Plan Template was less than adequate. The investigation found that the requirements for working around or near skylights were not clearly articulated in the BNL Health and Safety Plan Template. Furthermore, the investigation found that the contractors, who specialized in steel erection work, did not believe that there was a requirement to guard or cover skylights when personal fall protection is used.
Contributing Cause #2: The severity of the hazard was not recognized and mitigation, other than PPE, were not considered or implemented. The current fall protection personnel training course indicates that PPE (fall arrest system) is to be considered only when fall hazard mitigation, by means of prevention (by guarding or covering) or other travel restraint, is not feasible. This was not implemented during work activities.
Contributing Cause #3: The requirement for the BNL site specific fall protection plan differed from the Construction Safety Subject Area and the Health and Safety Plan (HASP). The contractor submitted their Fall Protection Plan as part of their Health and Safety Plan, however, the contractor's fall protection plan provided an exemption when "...conventional fall protection measures were used (i.e. guardrails, safety nets, catch platforms or Personal Fall Arrest System)." This exemption was not recognized during the BNL Safety Plan Review Phase.
Contributing Cause #4: The skylight hazard was identified in the field, but the risk posed was not assessed properly and was determined to be acceptable.
Contributing Cause #5: The multiple skylights on the roof were not clearly visible or identifiable yet the workers were expected to stay clear of them. During job scoping, the contractors did not identify the need to improve the visibility of the skylights.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>None provided.</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre>Jefferson Lab's Work Planning and Authorization Process provides for analyzing work hazards and identifying unmitigated hazards. Pre-job briefings, area walk-downs, and safety plan reviews are used to prevent less than adequate hazard mitigation practices. </pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">3/2/2021 2:49:08 PM by Bailey, Mary Jo</h5>
<pre>/</pre>
<h5 style="white-space:nowrap">3/2/2021 2:44:15 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those using fall protection PPE and Ladders:
SAF607: HAND TOOLS & LADDER SAFETY
SAF202: Know how to protect oneself from a fall of more than six feet
SAF202A: Be able to correctly fit fall arrest equipment
SAF307: Be familiar with using portable ladders safely
SAF202B: Know the JLab-specific safety requirements for fall protection</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1139</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">2021-JLAB-1139</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Best Practice</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">3/2/2021 2:34:17 PM</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">3/2/2021 2:49:08 PM</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">BNL</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">Jean Odin-McCabe, Institutional Lessons Learned Coordinator 631-344-6055 or odin@BNL.gov</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">522</td>
</tr>
<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
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<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">1 times</td>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=5864">BNL Skylight During Roofing Operations.pdf</a></li>
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<hr>
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<li>Subcontracts</li>
<li>Working at Elevations</li>
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<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF607: HAND TOOLS & LADDER SAFETY</li>
<li>SAF202: Know how to protect oneself from a fall of more than six feet</li>
<li>SAF202A: Be able to correctly fit fall arrest equipment</li>
<li>SAF307: Be familiar with using portable ladders safely</li>
<li>SAF202B: Know the JLab-specific safety requirements for fall protection</li>
</ul>
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<li>*Division Safety Officers (DSOs)</li>
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