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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1193">ACC-23-1018-A: Employee Sustains Injury to the Foot While Moving C100 String</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>On October 18th, around 10:30 AM, an Accelerator Division employee was working with a small team to manually move a C100 accelerator cavity string that was attached to a wheeled transport rail. The metal transport rail was approximately 25 feet long and 3 feet wide with four fully rotating caster wheels. As the loaded transport rail was being moved outside the clean room, an employee?s foot was run over by a caster wheel, injuring four toes of right right foot. The employee was immediately taken to a local hospital by a coworker.</pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>Movement of a cavity(C100) string from a Superconducting Radiofrequency (SRF) Test Lab area to a Cryogenic area, was planned for October 2022. Typically, when a cavity string is moved for maintenance or cleaning, it goes from one radiation control area (RCA) to another on a determined path. This time the cavity was being permanently stored in another location. The rail-system typically used to move a cavity string has handles (Photo 1) to facilitate the effort needed to push/pull the load, however, this time an alternate rail-system, without handles (Photo 2), was used.
<img src=" https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6786" width="600px">
After a pre-job briefing, the operation proceeded as typical. The load started moving and one of the technicians held the clean room curtains to avoid obstruction. Then the load started moving too fast, the technician attempted to slow it down, but the rail system had no handles making this effort more difficult and the curtains were also in the way. The effort caused the technician to lose focus and one of the wheels rolled over their toes.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>Moving cavity strings is considered a routine task by the group. They are well practiced and accustomed to moving strings from one location to another. This move involved a new location, where the group was unfamiliar with the travel path and an alternate rail system.
The weight of the load was not considered a hazard. Even though the load was well over a ton, it was distributed over a considerable distance. No specific personal protective equipment (i.e. steel-toed shoes) was required.
The work-briefing focused on movement instructions. There were three different groups working in the area at the time, but there was no coordination between them or the tasks. This potentially led to a more restricted work area for everyone.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>Require all rail systems, used to transfer cavity strings, be equipped with hand rails to assist in guiding the speed, maneuverability and safe distance of employees from string wheel paths.
Develop an operational safety procedure for cavity string movement. This will include topics for discussion during pre-job briefings, hazard and how they are mitigated, required personal protective equipment
Include clearly defined roles and responsibilities during string movement job briefings to encourage stronger focus amidst potential chaotic situations and changed environments.
</pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">12/13/2022 1:29:21 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in:
SAF502: Forklift Operator
SAF307: Ladder Safety</pre>
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<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1193</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-1193</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">10/26/2022 3:36:22 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">12/13/2022 1:29:21 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">Tony Reilly, SRF Operations, areilly@jlab.org</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">461</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">5 times</td>
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<li><a target="_blank" href="https://misportal.jlab.org/ll/downloadAttachment?attachmentId=6786">ACC-23-1018-A Photos 1&2.jpg</a></li>
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<hr>
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<li>Ergonomics - Lifting, Carrying, Repetitive Motion</li>
<li>Material Handling Equipment</li>
<li>Pinch Points</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF502: Forklift Operator</li>
<li>SAF307: Ladder Safety</li>
</ul>
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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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