EH-9310 Issue No. 10, October 1993 Occupational Safety Observer
OCTOBER 1993
Occupational Safety Observer
Unguarded Floor Openings:
WATCH YOUR STEP
Two unsuspecting employees were recently injured in separate incidents
involving unguarded floor openings. In both incidents, the employees fell
through unguarded and unmarked areas where floor panels had been removed
to facilitate maintenance tasks. Neither of the two injured workers was
involved in maintenance or construction activity; rather both were
conducting "business as usual" in areas they assumed to be free of
hazards.
The incident
The first incident occurred in a lodging facility at Argonne National
Laboratory-East on May 25, 1993. The uncovered floor access panel was
located in a 5 by 30-foot corridor used as a linen closet. Housekeeping
personnel routinely entered the corridor several times a day.
A maintenance worker removed the 3-foot-square access panel and climbed
down into the crawl space, looking for a leaking pipe. Once he found the
pipe, he climbed out and left the area to join his partner, who was in
another room. Because the worker expected to be gone for only a short
time, he left the floor access panel leaning against the wall and didn't
erect a barrier or post warning notices.
Meanwhile, a maid carrying an armful of linen went to the linen closet,
dumped the linen, and walked farther into the closet to reach for clean
pillowcases. Because her attention was directed toward the shelves, the
maid stepped through the opening and fell 3-feet to a dirt floor. She
sustained several broken ribs and a number of abrasions.
The second incident occurred on June 16, 1993, at the DOE Albuquerque
Operations Office. In this case, a floor access cover was removed to
facilitate installation of local area network cables by an electrical
contractor. The two maintenance workers assigned to the task thought that
the work would be completed quickly and that they would be present
throughout the operation. Accordingly, they did not post hazard warnings
or erect barriers. At one point during the operation, one worker left the
work area for a short time and the other ducked out of sight into the
subfloor area. While the opening was left unmarked and unguarded, a DOE
employee walked through the work area and fell into the floor opening.
The worker fell about 3 feet, incurring abrasions and broken toes.
Common threads
The parallels between these two incidents point out important lessons for
the entire DOE complex. Both incidents involved maintenance or project
work being conducted in work areas where hazards were not expected. Both
occurred while other workers, who had no reason to expect hazardous
activities that could cause them injury, were going about their daily
routines. In both cases, maintenance personnel failed to post hazard
warnings, erect barricades, or replace floor panels to protect passersby.
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In both cases, the hazard was left unattended "for a short period of
time."
It is important to note that the openings were a danger even when the
maintenance workers were in the area. In both instances, someone could
have fallen through an opening while maintenance personnel were occupied
with their work activities.
Lessons learned
Trip or fall hazards are particularly dangerous in offices and other
nonconstruction areas where employees are unlikely to suspect such
hazards. The incidents described in this article suggest the following
lessons learned:
Management must ensure that all personnel are protected from the temporary
hazards associated with maintenance or construction activity, as required
in OSHA regulations 29 CFR 1910.23(a)(7) and 1910.145(c)(3). Barriers,
signs, or other obstructions must be plainly visible to personnel entering
areas containing temporary hazards. Physical barriers are recommended.
The best protection is to cover an unattended opening.
Any time a hazardous area is left unguarded or unposted is too long. If
an area is to be guarded, the worker assigned to guard the hazard should
have no other duties.
Management must ensure that all personnel are trained to recognize
temporary hazards created by maintenance and construction activities.
References
CH-AA-ANLE-ANLEPFS-1993-0005
ALO--GOAL-ALMSD-1993-0002
Safety Focus on Good Practices:
CAMPAIGN RAISES SAFETY CONSCIOUSNESS
Most people have heard the adage, "Hindsight is 20-20." Employees of the
Maintenance and Operations Department of the Plant Engineering
organization at Lawrence Livermore National Laboratory are using their
collective 20-20 hindsight to think of ways to improve safety through a
program that concentrates on safety awareness, good work practices, and
other positive approaches to safety. Since last November, when the
program was established, the number of lost-time injuries for the
department has declined significantly.
How the program began
The safety awareness program began in 1992, when members of the Executive
Safety Committee decided to change their focus with respect to safety.
Occupational Safety OBSERVER Page 3
The committee's goal was to improve the department's safety culture.
Members of the Executive Safety Committee believed that if employees
thought about safety and the precautions that should be taken for each
job, then the safety culture would improve and the number of accidents and
injuries would decline. From the outset, this initiative has received the
full support of management.
The Executive Safety Committee in the Maintenance and Operations
Department consists of 27 members: one representative from each of the 18
craft shops in the department and 9 representatives from management and
other areas of the plant, such as training, hazard control, and standards
and documentation. Only the 18 craft shop representatives have voting
rights; the other 9 members serve the committee as subject matter experts.
Led by Bernie Mattimore, head of the Maintenance and Operations
Department, and Jerry Morgan, chairperson of the Executive Safety
Committee, the committee hired outside consultants to help create a
department-wide safety awareness program. One component of the program
involved creating a "safety value" statement:
Based on our concern for our employees and their families, we commit
ourselves to continue to nurture a culture that promotes safety, including
related health and environmental issues, on and off the job. We will do
this by personally instilling a positive attitude concerning safety in
ourselves and others.
Another component of the safety awareness program was a safety awareness
campaign designed to get Maintenance and Operations personnel directly
involved with improving the safety culture. As a result, November 1992
was proclaimed as Safety Awareness Month.
Safety Awareness Month
According to safety consultants at Lawrence Livermore, for every major
injury accident, there are 30 minor injury accidents and approximately 300
"near misses." The purpose of Safety Awareness Month was to encourage
employees to focus on and talk about the near misses. The committee
reasoned that if the number of near misses declined, so would the number
of accidents and injuries.
To involve employees, members of the Executive Safety Committee from each
shop announced plans for Safety Awareness Month during shop meetings,
asking employees to submit accounts of near-miss incidents they had either
witnessed or experienced personally. Because the safety awareness
campaign was tied to the department's safety value statement, employees
were invited to submit accounts of near misses occurring in or out of the
workplace.
Employees were then given forms on which they could write their names, a
description of the near-miss incident, information about corrective
actions they might have taken, and recommendations to management.
Employees placed these forms in "safety suggestion boxes" that were
located in every shop. Each participant received a sticker imprinted with
the safety value statement. Winners of the weekly drawings received
Page 4 Occupational Safety OSBERVER
engraved key chains. At the end of the month, all participants were
included in drawings for five $50 savings bonds.
By the end of the campaign, a participation rate of 76 percent had been
achieved. According to Jerry Morgan, "The campaign really brought out the
idea of safety awareness. Everyone was talking about safety!"
Followthrough activities
Safety awareness efforts did not end in November 1992. Accounts of
near-miss incidents submitted by employees were compiled verbatim into a
booklet. Examples of these near-miss incidents include the following:
"I observed a bicyclist running stop signs, crossing the street without
signalling, riding in crosswalks, and riding on the wrong side of the
road."
"A plumber loaded some lengths of steel pipes on a rack on his truck. He
was in a hurry and forgot to tie the pipe and went down the road. A
pedestrian was crossing the road and as the plumber slowed his truck, the
pipe slid off nearly hitting the pedestrian with the pipe. Never be in a
hurry. Check your load to see if it is secured."
"My partner was using a 5" grinder without [wearing] a face shield. I
reminded him that grinding wheels come apart. Three to four minutes
later, the wheel disintegrated. He was wearing a face shield."
"I observed a custodian pushing trash down into a barrel with her hands."
Excerpts from the booklet are read and discussed during monthly shop
meetings.
The safety awareness program has been a great success--not only in terms
of employee participation, but also in terms of better safety practices
within the department. Jerry Morgan reports: "We have seen a decrease in
lost-time injuries in the department, and now other departments are coming
to ask us how to set up a safety committee and safety awareness month."
The Maintenance and Operations Executive Safety Committee plans to hold
its next safety awareness campaign in November 1993. During that
campaign, the committee hopes to hold "town meetings" in each shop,
inviting participants to talk about specific incidents and how they might
have been avoided.
If your department is interested in more information about this program,
or if you would like information on how to set up a safety committee and
safety awareness campaign in your organization, contact Jack Tolley,
Safety Manager for Plant Engineering, at (510) 423-6635. Also, if you
have a program or good practice that is particularly successful--or if you
have information to share concerning lessons learned from near
misses--please contact the Observer's Coordinating Editor at (301)
903-7328.
Sandblasting Incident:
Occupational Safety OSBERVER Page 5
WORKER RECEIVES ABRASIONS TO HANDS
Failure to maintain and operate equipment properly is a common theme for
many incidents reported in the Observer. Once again, the incident
described below probably would not have occurred if proper maintenance,
inspection, and verification of the operability of equipment had been
performed.
The incident
On June 24, 1993, workers at the Oak Ridge Y-12 Plant were sandblasting
the exterior surfaces of three 100,000-gallon waste storage tanks in
preparation for repainting. Each sandblasting machine was staffed with a
two-person crew: a nozzle operator, who was assigned to direct the flow
of abrasive material, and another worker assigned to maintain the abrasive
material in the blast pot.
When one of the nozzle operators observed that abrasive material was no
longer flowing through the nozzle of his machine, he suspected a clog in
the blast hose. He responded by releasing the pneumatic control switch
(which is designed to depressurize the system automatically) and signaling
his coworker. Assuming that the system had depressurized, the coworker
attempted to disconnect the blast hose from the equipment in order to
clear away the suspected clog. He failed to recognize that the blast hose
was completely rigid, an indication that it was still pressurized.
The coworker was unable to rotate the quick-disconnect coupling the
one-quarter turn required to remove the blast hose. Apparently assuming
that the fitting was stuck because of dirt or contamination, and without
considering that the resistance in the coupling could be caused by a fully
pressurized system, he summoned another worker to assist him. Acting
together, the two workers were able to twist the hose fitting to the point
where it could be forcibly disconnected. The system rapidly
depressurized, spewing abrasive material through the coupling and onto the
hands of the worker nearest the outlet. The worker sustained relatively
minor, but painful, skin abrasions to both hands.
Both workers were fortunate that their eyes and faces were not injured,
and the injured worker was lucky that his wounds did not become infected
from embedded sand.
Results of the investigation
The sandblasting machine involved in this incident was a CLEMCO Model
2452, a relatively common piece of equipment. The machine consists
primarily of a pot to hold the abrasive material and a flexible, 1-
inch-diameter blast hose to carry and direct abrasive material to the
surface being cleaned. The machine is designed to be connected to a
compressor and to operate at a pressure of 100 psi.
The pot can be pressurized and depressurized by the blast-hose-nozzle
operator using a pneumatic switch, or "dead man's" switch, which controls
and synchronizes air inlet and outlet valves located on the pot. When the
operator engages the "dead man's" switch, the air inlet valve opens, the
air outlet valve closes, a pop-up valve inside the pot closes to seal the
Page 6 Occupational Safety OBSERVER
pot, and the pressure in the pot forces sand through the blast hose. When
the switch is disengaged, the air inlet valve closes, the air outlet valve
opens, the pressurized air in the pot depressurizes through the air outlet
valve and the blast hose, and the pop-up valve opens to allow more
abrasive material to be added to the pot.
Because the pot can be depressurized only through the blast hose or
through the air outlet valve, the fact that it failed to depressurize when
the blast hose was clogged indicates that the air outlet valve was stuck
in the closed position. CLEMCO equipment mechanics told the Observer that
air outlet valve failures generally occur when the air outlet abrasive
trap (a filter screen that protects the valve from abrasive materials
carried in rapidly venting air) is not cleaned regularly. CLEMCO
recommends that the abrasive traps be cleaned twice daily whenever the
equipment is in use.
Lessons learned
This incident offers lessons learned that apply to both maintenance and
training:
Preventive maintenance schedules should be developed and followed. The
absence of such maintenance can lead to unexpected equipment failure,
which in turn can lead to personnel injury. Management should review
existing preventive maintenance programs and emphasize the importance of
following recommended procedures.
Training on equipment should include recognition of warning indicators
that are specific to each piece of equipment. In this case, workers
failed to recognize that the rigid blast hose and the resistance of the
quick-disconnect coupling were indicators that the system was still
pressurized.
Training on pneumatic equipment should include discussion of appropriate
procedures for assisting operators to determine whether a given system has
been depressurized. A safety check, such as requiring the operator to
squeeze the blast hose and observe its collapse before disconnecting the
hose, would have prevented this incident.
Reference
ORO--MKFO-Y12CENTENG-1993-0024
Worker's Toes Fractured:
LIFTING ACCIDENT LEADS TO HOSPITALIZATION
Lifting accidents may occur even when the items being lifted are within
accepted weight limits. This article describes an accident at Lawrence
Livermore National Laboratory in which a worker dropped a relatively light
object during an awkward lift and injured his foot.
Occupational Safety OBSERVER Page 7
The accident
During the afternoon of May 25, 1993, a worker who was trying to verify
the fit of a part attached to a tank dropped the part and broke two of his
toes. The worker was lifting a plate-mounted transducer assembly to a
feed-through port located nearly 6 feet above the floor of the tank. The
26-pound assembly consisted of a steel disk that was approximately 8
inches in diameter and 2 inches thick. While the worker was lifting the
assembly into position, the disk slipped from his hands and struck his
right foot.
This accident has been attributed to human error. Even though the
assembly was within established weight limits for a single-person lift,
the worker had to position it high against the curved wall of the tank.
When the assembly fell, the worker's failure to wear safety shoes
contributed to the severity of the injury.
Lessons learned
Workers should be trained to recognize the hazards associated with
lifting, even when a lift is within established weight limits. Lifts can
be complicated by factors other than weight, including the height of the
reach, lack of visibility, uneven floor surfaces, and the availability of
a safe final resting location for the object lifted. These factors can
increase the risk of such injuries as pulled muscles, strained joints, and
broken bones. Most workers are familiar with proper lifting techniques
for standard lifts--lifting with the legs and not the back, for example.
However, the lifts workers are required to perform on the job may be more
complicated. In this case, the use of a stepstool could have helped to
avoid overreaching while the worker attempted to verify the fit of the
transducer assembly. Portable lifting devices are available to help
workers with awkward lifts.
The safety poster included in this issue describes proper lifting
techniques for a variety of difficult loads.
Personal protective equipment might also help workers avoid lifting
injuries. Safety shoes, or steel-toed shoes, are recommended if there is
potential for a lifted object to fall. Back braces are available,
although their benefits are currently being debated by the ergonomics
community. According to Dawn Mitchell, an ergonomics engineer at Human
Fit, Inc., the most effective ways to decrease lifting injuries involve
"designing the workplace to fit the worker, in conjunction with employee
education and training."
The importance of reducing lifting injuries can be seen in data published
by the National Safety Council. In 1991, the type of on-the-job injury
that occurred most frequently was back injury. Back injuries accounted
for 22 percent of all disabling work-related injuries--a total of 374,000
back injuries for the calendar year.
Additional information on lifting is available from the National Institute
for Occupational Safety and Health in its 1991 Work Practices Guide for
Manual Lifting. (This information may be obtained from the National
Technical Information Service at 703-487-4650.) Further, the chief
Page 8 Occupational Safety OBSERVER
ergonomist for OSHA predicts that his agency will issue a final ergonomics
standard encompassing prevention of back and other musculoskeletal
injuries by late 1995.
Reference
SAN--LLNL-LLNL-1993-0040
Correction:
We'd like to take this opportunity to thank one of our readers for
catching an error in the August 1993 Observer. In the article entitled
"Balancing the Load," 29 CFR 1926.550(a)(1) was incorrectly cited as 29
CFR 1926.500(a)(1).
Accident Investigation Guide Available:
Practical Guidance for Accident Investigation and Reporting is a new
handbook available from the Office of Safety and Quality Assurance. This
handbook provides brief guidance statements concerning the conduct of
accident investigations. Although written specifically for DOE, the
handbook contains information that should be applicable to other accident
investigation processes.
If you would like a copy of this handbook, please contact Towanda O'Brien,
fax (206) 528-3552, telephone (206) 528-3237.
FEATURE ARTICLE
Part 2:
DOE COMPLEX TAKES A CLOSE LOOK AT HANFORD FATALITY
Last month, the Observer reported on the June 1993 fatality at the Hanford
Site. This accident occurred when a thermal water hammer caused a valve
to fail catastrophically, releasing large amounts of steam into the
enclosed, underground pit where the fatally injured employee was working.
This month, our focus is on the lessons learned from the accident
investigation and the implications of these lessons for the DOE complex.
A "routine" operation
The Accident Investigation Board's (AIB) analysis of the Hanford accident
showed how a series of events involving design and procedural
deficiencies, training inadequacies, and poor management decisions formed
a chain of events ending in tragedy.
As determined by the AIB, the decisions and actions that led to this
accident were made by DOE management within a system that focused on
nuclear rather than nonnuclear hazards. In day-to-day activities
Occupational Safety OBSERVER Page 9
conducted over several years, management failed to recognize all of the
dangers inherent in operating a steam system. Consequently, managers and
workers took action, or failed to take action, based on the belief that
this nonnuclear system was relatively safe--that it was a "routine"
operation. No single action that contributed to this long chain of events
involved significant risks. Collectively, however, these actions
resulted in a employee's death.
This failure to recognize the hazards and risks associated with "routine"
activities is not unique to Hanford. Similar assumptions are made at
virtually every DOE site.
Learn, not blame
The lessons learned from this accident were presented at a complex-wide
workshop held at Hanford on August 25-26, 1993. The purpose of the
workshop was to draw on expertise from across the DOE complex to develop
global lessons learned and corrective actions. The workshop was the first
of its kind for DOE, and it was attended by about 110 safety
professionals.
Speakers from DOE, Westinghouse Hanford Company, and organized labor
presented their perspectives on the accident and discussed the steps being
taken to prevent similar occurrences. In his opening remarks, Oliver D.T.
Lynch, Jr., Director of DOE's Office of Performance Assessment (EH-32),
emphasized that people had come to this workshop "to learn, not to blame."
Robert W. Barber, the AIB Chairman and Director of the Office of Risk
Analysis and Technology (EH-33), described the accident, its causes, and
the Board's findings. After the formal part of the program, the
workshop's participants separated into four subgroups to discuss measures
that could be taken to prevent such accidents in the future.
The subgroups provided participants with a forum for sharing problems and
potential solutions to prevent recurrence of similar accidents.
Lessons learned
The consensus of the participants in the Hanford workshop was that the DOE
complex must do a better job of protecting the safety and health of
personnel involved in routine, nonnuclear activities. The lessons learned
and corrective actions developed by the four subgroups focused on the
following areas:
Occupational Safety and Health: Members of this subgroup emphasized that
managers and workers must start with the assumption that all tasks are
potentially dangerous. Sites should develop interactive, proactive safety
practices to involve personnel at all levels in the process of recognizing
and controlling hazards. Such a process should include the development
and implementation of improved procedures, better training programs, more
and better hazard analyses, formal prejob briefings, as-built
configuration management, and engineered barriers and controls for
worksites identified as hazardous.
Conduct of Operations: Participants in this subgroup stressed the
importance of communications--hazard communications in particular--in all
Page 10 Occupational Safety OBSERVER
aspects of the conduct of operations. Site management must find effective
ways to emphasize safety and the importance of following procedures.
Effective mechanisms should be established to solicit employee
participation and feedback on issues related to safety and job planning.
Employees should consult with and obtain approval of supervisors whenever
there are changes to the job plan or deviations from established
procedures. Communications between sites should also be improved to
facilitate the complex-wide dissemination of lessons learned from
significant events.
Management: Members of this subgroup emphasized that management should do
a better job of providing oversight for nonnuclear systems. Lines of
authority and responsibility should be clearly defined. Managers should
conduct frequent and thorough reviews to ensure that work practices are
safe and that hazardous work environments are identified. All levels of
management should increase the quality and quantity of the time spent
"walking their spaces."
Training: Members of this subgroup suggested that DOE 5480.20 be revised
to include training for nonnuclear activities. Management should ensure
that training is current and that training records are properly
maintained. Standards for on-the-job training should be established, and
workers should be aware of these standards. Employees should be trained
to stop and think about the implications of their actions in terms of
safety--not simply to respond. Workers should never attempt to perform
tasks for which they are not fully qualified.
As the workshop participants recognized and acknowledged, these lessons
learned and corrective actions overlap--and they are not new. The
significance of this workshop process lies in the renewed commitment by
the complex (1) to work toward recognizing and solving problems related to
safety, and (2) to find effective means for communicating that information
to all concerned.