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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1151">Missed Work Planning and Control Activity, After Scope Change, Results in Injury - Pacific Northwest National Laboratory (PNNL)</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>While assisting in manually moving a ~700 pound, 8 × 12-foot wooden platform at Pacific Northwest National Laboratory (PNNL) a staff member injured their back. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On March 1, 2021 a scope of work was initiated for the construction of an outdoor wooden platform. During a walk down of the location where the platform would be utilized it was decided that it should also be painted to deter "weathering." This was not considered an additional activity, nor was it included in the original scope of work.
When the incident occurred the ~700 pound, 8 × 12-foot wooden platform was resting on two sawhorses and needed to be flipped so the opposite side could be painted. Before moving the platform, five staff members, including a Work Team Lead, met to develop a plan to flip the platform over. It was decided to utilize a forklift for the maneuver. The forklift was brought in which lifted the platform off the sawhorses, laid it on the ground, and then flipped it over with manual assistance from the staff members.
The forklift then attempted to lift the platform back onto the sawhorses but it was not properly centered on the lifting forks. The staff members then chose to position themselves around the platform and manually lift it to center it on the forks. During this manual-lift one staff member felt a sharp pain in their back but did not report the sensation to the Work Team Lead who was assisting with the lift activity, rather they continued to work throughout the day. The following morning the staff member informed their Work Team Lead about the incident and the persistent back pain. This Work Team Lead then contacted the PNNL Security Operations Center and reported the injury.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The scope of work was not updated to include painting activities. It was subsequently determined that the additional work activities required to paint the platform included:
- Additional material handling to transport and maneuver the ~700 pound, 8 x 12 foot platform.
- Actually painting the platform.
Three Work Team Leaders were identified as responsible for the work activities. One initiated the scope of work to build the platform. The second was responsible for the painting and subsequent maneuvering activities. A third actually assisted in turning the platform over. After the back injury was reported, staff involved were unclear as to which Work Team Lead was responsible for the activity that caused the injury.
All staff involved were unclear as to whether a pre-job briefing defining the hazards had been performed for the associated movement of the platform activities.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>When the scope of work added painting the platform, it was not properly documented per procedures. A new or addition to the original scope of work should have been initiated to identify related hazards and develop safety controls for painting activities.
Staff members, who turned over the wooden platform, were unclear which Work Team Leader was responsible for the work or whether a pre-job briefing had been conducted. For dispatch activities, a Work Team Leader does not have to be present during the execution of the work, but work control planning discussions must be held by the Work Team Leader. Staff should have paused work when it was realized that a pre-job briefing had not been conducted and utilized the 5-Key Questions for a self-directed briefing.
All staff involved realized the weight of the wooden platform presented a hazard, and a forklift was utilized to rotate the platform. However, when the staff decided to partially lift and push the platform to center it on the forks they overlooked the hazards associated with physically lifting an object weighing ~700 pounds.
During the execution phase of work material handling procedures were not followed. These would have provided guidance considerations regarding material handling through a checklist. The first consideration on the checklist is the estimated weight of an item being lifted.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">7/21/2021 3:22:03 PM by Bailey, Mary Jo</h5>
<pre>submitted to those current in:
SAF502: Forklift Operator
MED05: Safe Lifting (Ergonomics)</pre>
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<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1151</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-1151</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">YES</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">7/21/2021 3:14:02 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">7/21/2021 3:22:03 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">PNNL</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">Laura Valett, Operating Experience / Lessons Learned Program Manager, Laura.Valett@PNNL.gov (509) 372-4959</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">301</td>
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<tr class="row">
<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>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Ergonomics - Lifting, Carrying, Repetitive Motion</li>
<li>Material Handling Equipment</li>
<li>Powered Industrial Trucks - Forklift with Attachment</li>
</ul>
</fieldset>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF502: Forklift Operator</li>
<li>MED05: Safe Lifting (Ergonomics)</li>
</ul>
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<li>*Division Safety Officers (DSOs)</li>
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