Lesson Learned Statement:Occasionally controls implemented to mitigate hazards identified during pre-job planning can introduce other unidentified hazards into the job. Those additional hazards must be adequately controlled to maintain a safe work environment.
Discussion:Recent work in the 324 Building involved the removing and bagging HEPA filters and placing them into a staged waste box. During the Automated Job Hazard Analysis (AJHA) process, work site walk down, and work package development, personnel who were to perform the work requested that the waste box be pre-staged at the edge of the loading dock to facilitate placing bagged filters into the box. The workers decided that carrying bagged filters up a ladder against the side of the box and then lifting the bags over the side of the box posed an inappropriate risk. However, the location of the box next to the loading dock required the workers to lean over the edge to place filters into the box while supporting their bodies with their free hand. The arrangement resulted in undesirable ergonomic positioning and the possibility of falling into the box. The workers eliminated the falling hazard by jumping into the four foot deep box to position the bagged filters.
Analysis:The decision not to use a ladder during the AJHA process was based on the inherent hazards associated with ladder use compounded by the workers carrying filters in one hand. While this was an appropriate thought process and decision, the alternative process created an unforeseen hazard. The ladder hazard was eliminated but was replaced by an ergonomic/fall hazard.
Recommended Actions:As hazards are analyzed and controls identified through the AJHA process, alternative safety measures and controls must be scrutinized for their own associated hazards. Frequently alternative measures are established that have unique safety hazards and implications. Those hazards must be recognized and controlled to ensure a safe working environment.
Originator:Originator: Fluor Hanford, Inc. Submitted by John Bell
Contact:John Bell (509) 372-2291 or Project Hanford Lessons Learned Coordinator; (509) 373-7664; F
Name Of Authorized Derivative Classifier:Not required
Name Of Reviewing Official:John Bickford
Priority Descriptor:Yellow / Caution
Keywords:ladder, waste packaging, ergonomics
References:HNF-PRO-079, Hazard Assessment
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DOE Function / Work Categories:Conduct of Operations - Work Planning
Material - Material Handling
Occupational Safety & Health - General
Packaging & Transportation
ISM Category:Analyze Hazards
Develop / Implement Controls
Hazard:Ergonomics / Lifting
Elevated Work / Falling Objects
Personal Injury / Exposure - Slips & Tripping
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