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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1172">CST-22-0315: Employee Receives Foreign Body and Corneal Abrasion in Left Eye</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>An employee was asked to assist in retrieving an access panel and tape that had been dropped by an accessor robot within an enclosed tape library in the Data Center. After retrieving the items, the employee experienced eye irritation. A foreign body was later removed from the surface of the cornea. A protective contact lens was applied and antibiotic eye drops were prescribed to treat the abrasion. ESH categorized the event as OSHA recordable (DART) and CAIRS reportable.
<img src=" https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6426" width="250px"> </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>On March 15, 2022 an employee was asked to assist with an issue having to do with the accessor robot in the Data Center Tape Library. The robot had dropped a tape reader's access panel and a cassette onto the floor inside one of the reader cabinets. The employee entered the cabinet and retrieved both the cassette and the panel. Shortly after the employee began experiencing irritation in the left eye. The condition worsened over the next few hours resulting in blurring vision. The employee sought medical attention at the local emergency facility where a doctor removed a foreign body from the surface of his cornea. The doctor applied a non-prescription contact lens as a bandage, and prescribed antibiotic eye drops to treat the abrasion to the cornea. </pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>NOTE: The causes for this event are considered speculative and are solely based on an analysis of the equipment and the actions of the employee.
No error precursors or failed defensive conditions were found. The cabinet's access door is equipped with a sensor that, when opened, interlocks the robot effectively disabling it. The cabinet manufacture did not communicate the need for personal protective equipment when accessing the cabinet.
It is considered most likely that upon opening the cabinet's access door, to retrieve the fallen tape and panel, a small piece of debris was disturbed, becoming airborne, and landing on the employee's cornea.
The accessor robot itself moves on tracks in both the X and Y planes, riding on a bearing system. This repetitive movement could, over time, wear on materials resulting in small (dust-size) particles to accumulate on the infrastructure surfaces inside the cabinet. When disturbed, these could become airborne.
Each tape reader drive is equipped with cooling fans. These fans are not subject to the interlock system. Change in pressure, resulting from the opening of the cabinet door, could cause the accumulated material to become airborne and blown about.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>The Tape Library will be evaluated for potential hazard conditions associated with entering the equipment. The resulting Task Hazard Analysis (THA) will be provide the controls necessary to achieve acceptable risk levels.
Those who access the area will be required to implement the controls as documented in the THA.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">5/13/2022 12:44:26 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in SAF133: Task Hazard Analysis for Supervisors</pre>
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<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1172</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">2022-JLAB-1172</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">3/29/2022 9:23:58 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">5/13/2022 12:44:26 PM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
TJNAF NE
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</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">Amber Boehnlein, Associate Director Computational Sciences and Technology, Amber@jlab.org</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">104</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">2 times</td>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6426">IBM TS4500 Tape Library Internal View.png</a></li>
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<hr>
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<legend>Hazard Issues</legend>
<ul class="lesson_attribute_listing">
<li>Air Contaminants - Hazardous</li>
<li>Confined Space</li>
<li>Other: Safety Document Review</li>
</ul>
</fieldset>
<fieldset>
<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF133: Task Hazard Anaylsis for Supervisors</li>
</ul>
</fieldset>
<fieldset>
<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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