EH-9405 Issue No. 5, May 1994 Occupational Safety Observer
MAY 1994
Occupational Safety Observer
Fall Protection Works!
WORKER FALLS FROM ROOF
by Eva Jean Bryson
"If any fall hazard is allowed, given time, it will prove lethal" That
statement was made by J. Nigel Ellis, one of the foremost authorities on fall
protection and prevention in the United States. Fortunately, that statement
was not proven true in a recent incident that occurred at the Rocky Flats
Plant near Golden, Colorado.
On February 4, 1994, an insulation worker fell through an unfinished
roof, sustaining only minor injuries. The worker's good fortune was
attributed to the fact that he wore a full-body harness connected
by a shock-absorbing lanyard to a shock-absorbent static line.
These fall-protection devices were the result of (1) proactive oversight by
the Rocky Flats Office (RFO); (2) support by RFO management; and (3) effective
corrective actions by EG&G Rocky Flats, Inc., the management and operating
contractor.
Improved fall protection
Before this incident, the RFO Occupational Safety and Health (OSH)
organization had stopped work temporarily on this project because of
inadequate fall protection. RFO management fully supported the OSH
determination to halt work temporarily so as to afford greater protection for
the workers. Repeated meetings between RFO-OSH and EG&G's occupational safety
group determined that the current fall protection system was inadequate.
After discussions with DOE, EG&G required the project subcontractor to provide
a 100-percent fall-protection system. The subcontractor responded by
providing a static line with shock-absorbing features. The system requires
all workers to wear a full-body harness and connect to the line using a
shock-absorbing lanyard.
The insulation worker subcontracted to EG&G was walking backward
installing insulation when he stepped off the support beam and fell. The
distance from the roof of the structure to the concrete floor was
approximately 20 feet. Because of the protective devices he wore, the worker
fell only 8-11 feet.
The fall arrest system saved the employee from serious injury or death.
Despite that protection, the lower part of his body did come into contact with
deenergized electrical equipment inside the structure. He was therefore taken
to the Rocky Flats Medical Center for initial treatment, then transported to a
local hospital for x rays. He was treated, released, and returned to work the
same afternoon.
The investigation
The investigators concluded that the combination of two shock-absorbing
units increased the allowable fall length to an unacceptable distance. The
shock-absorbing cabling system contained a unit intended for use with
retractable lifelines. The workers used shock-absorbing lanyards instead.
Therefore, when the worker fell, the cabling system provided for a fall
distance of about 2 feet and the lanyard provided for a fall distance of about
6 feet. These systems are also intended to be used at heights above 20 feet
and in areas clear of obstructions. The newly installed electrical equipment
presented hazards that this type of system was not designed to mitigate.
The RFO-OSH organization worked closely with EG&G's occupational safety
group to identify deficiencies in the project's fall protection program, to
determine which corrective actions were best, to promote understanding, and to
encourage compliance by the subcontractor.
Lessons learned
This incident provides several lessons learned:
-- When a fall protection system is initially installed, all potential fall
distances should be analyzed to ensure that appropriate equipment is used both
to mitigate the hazard and to reduce the fall distance.
-- Management must ensure (1) that employees are properly trained in the use
of fall-protection devices and (2) that such systems are in place and
operating properly before work begins.
-- Proactive oversight and teaming create the "win-win" habit. Emphasizing
and reinforcing this habit encourage changes in work conditions, behaviors,
and attitudes that can prevent future incidents like this from taking place.
[Eva Bryson has worked for the DOE-RFO Occupational Safety and Health Physics
Division for 4 years. She is a safety and occupational health specialist with
oversight responsibility for all construction work at RFO, including safety,
hygiene, and environmental regulations relative to construction.]
A Worker's Story:
LOSING A FINGERTIP* by Kevin Ireton
[This article first appeared in the September 1993 issue of Fine Homebuilding
magazine. The article provides valuable lessons learned related to (1)
machine guarding, (2) the correct use of tools, and (3) the importance of
training. It also conveys the serious repercussions of an accident--in this
case, an accident that could have been much worse. We encourage managers to
distribute this article to their workers.]
On September 16, 1985, I sat on the examining table and watched a woman
with a mop and a bucket on wheels clean up the blood that I had just trailed
into the emergency room. She never looked up to see where the trail led.
I was waiting for the doctor. A nurse had already unwrapped the bloody
shirt from around my hand, pulled off my wedding ring and surveyed the damage.
I cut off the tip of my ring finger on my left hand at the last knuckle.
I also cut my thumb and little finger; those would both heal 100 percent. My
ring finger, however, would never be the same. The piece that I severed was
ground up by the carbide-tipped blade on the table saw.
I felt stupid because of what I had done and embarrassed at being so
stupid. I remember thinking it wasn't worth it--being a carpenter. What was
the point? A meager hourly wage, little or no respect, and risking this. I
could have done as much with a car door, or an electric fan, or a dozen other
household devices. But it wasn't a car door; it was a table saw, one of the
fundamental tools of my trade. I kept a journal at the time, recording my
struggle to understand and accept what had happened. As injuries go, it
wasn't a big deal. One friend characterized it as "just a warning." Once my
hand healed, I could pretty much do everything I had done before. But the
accident affected me far more psychologically than it did physically. I had
to accept that I was not invulnerable, and as a consequence I began to take
more seriously my responsibility for learning to use tools properly, and I
also started to pay more attention to the little voice inside my head. In
short, I became a safer carpenter. Recently I reread my journal entries
concerning the accident, and I wondered if the entries might help others
benefit from my experience. It is with that in mind that I present the
following journal excerpts.
Sept. 19: How the accident happened--My priority the morning of the accident
was to shim the cast-iron tub to the proper height for the marble tiles that
were soon to be installed in the master bedroom. Ron and Scott were replacing
a large set of casement windows in the library. I took all the measurements
that I needed and headed downstairs to the table saw.
One of the shims had to be 3/8 inch thick. I set the saw at 3/8 inch
between the blade and the fence and raised the blade height to half the width
of my board, about 2 inches. I was cutting a scrap of baseboard about 16
inches long, and I thought it would be wasteful to use the whole thing when
all I needed was a 4-inch piece, so I just fed 6 inches into the saw, then
withdrew it. Here is where I made the most serious mistake.
I should have shut off the saw and reset the fence so that I could turn
the board over and be cutting at 3/8 inch on the far side of the blade. But I
didn't want to go to that trouble. I decided I could reach over the blade and
plunge cut the last 6 inches of the board. It was about this time that Ron
called to me from outside. I reached to shut off the saw, then decided to go
ahead and finish what I was doing before seeing what he wanted.
As I was lowering the board into the saw, I got it twisted and bound.
The saw jerked the board out of my hands and threw it through the window
behind me, 50 feet into the street. My left hand, which had been applying
pressure against the board and toward the fence, went into the blade. I had
to look at the hand to know what had happened. I don't remember shutting off
the saw, but I did at some point. Then I called to Ron and Scott, "Which of
you is going to drive me to the hospital? I just cut my hand on the table
saw." I remember Ron thinking that I was kidding.
Sept. 21: A period of adjustment--I have now had six days to adjust to my
accident and loss. The questioning of my career as a carpenter is pretty much
over. The pain in my hand is no longer generalized but has reduced itself to
a very specific soreness at the end of my finger.
Mental and physical strength, along with the wonderful narcotic effects
of shock, carried me through the morning and afternoon of the accident. The
worst physical aspect was not the accident itself, but later, at the doctor's
office, listening to the awful crunching sounds as the hand surgeon clipped
away the shards of bone and rounded the end of the shortened fingertip.
The flashbacks were the most disturbing and the hardest to control. I
kept looking down and seeing the ragged, bloody finger--an ugly hole where the
tip had been. The vision shook me again and again. But time, merciful time,
has robbed the scene of much of its dramatic effect. I can now call forth the
image at will and look on it with equanimity.
At the doctor's office today, it took a long time to get the bandages off
my finger. I had to soak them in warm water and then slowly, painfully unwind
them. After I finally got the bandages off, I sat on the examining table to
stare at the hand, to begin getting used to it. Just then the nurse brought
another woman down the hall to wait on the couch outside my door. It occurred
to me that she might not be as anxious to study my bloody stump as I was, so I
got up and closed the door.
Sept. 27: Going back to work--I was back at work on the job site this week.
Wednesday and Thursday I put in full days. It was frustrating not to be able
to do some things. I did, of course, bang my hand occasionally. I tired
easily. But I believe that working has been good for me. It has lifted my
spirits and taken my mind off things.
I was back on the table saw, too. It was hard. My fear at times was
almost paralyzing. Part of the fear stems from the fact that I don't have
full use of my left hand and so cannot control the work as well. But the
biggest part of the fear is just fear. Hearing the high-pitched whine of the
motor and the rumble of the vibrating table makes my hand ache. And being
back at work after the accident means facing the fact that it could happen
again.
Sept. 28: Breaking the rules--I learned to use the table saw the same way
that I've learned to use all my tools: on the job site, through experience
and observation--the latter more than the former. I was at the mercy of those
around me and their knowledge and safety habits. There was no system of
training, no regulation of the use of these tools. But this is no excuse. I
should have taken it on myself to learn the rules.
As a result of the accident, I've been reading magazine articles and
books, trying to learn about correct tool operation and safety. It was a
confluence of mistakes, or rule violations, that caused my accident:
1. I was working with a short piece of wood, and although it was longer than
the usual suggested minimum of 12 inches, it was still too short to be safe.
2. I was resawing on the table saw, which is always a risky operation.
3. I was attempting a plunge cut, which is dangerous in many ways. I was
doing this to save a 12-inch piece of wood for possible future use. How
stupid can you get?
4. I wasn't using any safety precautions--guards, push sticks, featherboards.
Only the featherboard would have been usable in this operation. It's the one
that would have saved my fingertip.
5. I was distracted. Ron called for me just before I made the cut. I
reached to turn off the saw, then changed my mind, deciding to finish the job
before seeing what he wanted.
6. I ignored the little voice in my head that was saying, "You probably
shouldn't be doing this; it's dangerous."
That's a lot of things to be doing wrong at once, but the biggest mistake
was that I didn't even know all the rules I was breaking.
Oct. 10: Safety isn't the prime concern--For most carpenters, myself
included, safety is not a regular part of the mental process. Productivity is
usually the prime concern. What is the fastest way I can get this job done?
Sometimes quality is the prime concern. How can I achieve the best finished
product? Whichever is the first, the other runs a strong second and tempers
whatever decisions are made.
I don't, as a regular consideration, ask myself, "What is the safest way
of doing this job?" Only when my instincts wave a flag, and the little voice
in my head shouts, "Hey, this is dangerous," do I consider safety. And it is
always relative.
There is danger inherent in all power tools, all cutting tools, hammers,
pliers ... danger of a serious fall every time I step above floor level onto
a stool or a ladder or a scaffold. None of the work is ever 100 percent safe.
I'm always arguing with the voice in my head, weighing the risk, factoring
and compromising.
Instead of going downstairs to get a ladder, I stand on an upturned
bucket because it's easier and quicker. The little voice says it's dangerous,
but I think I'll be all right. Most of the time I get away with it. On those
rare occasions when I don't, all that usually happens is that I slip off the
bucket, land on my feet and say to myself, "Yes, I guess I better go get the
ladder."
But there is the chance that I could fall off that upturned bucket and
break my leg, or hit my head, or lots of horrible things. Then I'd ask
myself, "Why was I so stupid? Was I really trying to be productive, or was I
just being lazy?"
Unfortunately, the other carpenters around me can have unhealthy effects
on my willingness to listen to my own instincts. They can make me feel
cowardly.
I'll never forget the morning I got down off the roof because the
shingles were slippery with dew. I told Bob I didn't think it was safe up
there and that I'd work at something else until the sun reached that side of
the house. A few minutes later Bob was up on the roof nailing shingles where
I had just been. It made him seem courageous and smart, when actually he was
probably being stupid.
Oct. 21: Small loss, big change--Six weeks with the hand today. It looks
good, isn't too sore. The finger and the hand are still swollen most of the
time. I can't make a tight fist. A Band-Aid and a piece of tape will be all
I'll wear on the finger today. I see the doctor on Wednesday. After that
it'll be six to eight weeks before I see him again.
At work I am unaware of it except when I have to use the table saw. Part
of me is worried that already I've become complacent. But another part
believes that the body has just taken over to get me back to work, productive,
feeling good about myself as part of the emotional healing. My mind is then
free to move, however slowly, toward assimilating all that has happened.
I actually lost very little--a finger tip--and yet the effects of this
loss are far-reaching. Perhaps because it is so easy from this vantage point
to extrapolate, to imagine losing the whole finger, a hand or even an arm.
All of this from the loss of something smaller than a cigar butt.
If you are ever going to go back to work after an accident like mine,
there are two things that you must do. First, settle in your mind how and why
the accident happened. And second, while accepting that it could happen
again, you must do what you can to ensure that it won't.
[Kevin Ireton is the editor of Fine Homebuilding and regularly uses the
featherboard and the push stick that he made for himself shortly after the
accident.]
Scaffolding Collapses:
CONSTRUCTION ACCIDENT KILLS ONE, INJURES TWO
On September 28, 1993, five workers were on a seven-story-high scaffold
when, without warning, it collapsed with a roar, sending men, bricks, and
scaffolding crashing to the ground. One worker was killed, and two others
were seriously injured. The 71-foot-high scaffold had been erected at a
commercial site to construct a brick facing on a new building.
An investigation by OSHA determined that the collapse was caused by
several violations of standards for scaffolding: (1) the scaffolding had been
modified by cutting off lower horizontal chords (structural members); (2)
improper cross-bracing had caused it to be out of plumb, thereby reducing its
rigidity; (3) damaged components had not been properly repaired; and (4) the
scaffold was loaded with "construction materials beyond the scaffold's maximum
rated load capacity." OSHA standards for scaffolding are provided in 29 CFR
1926.451.
Weather conditions also contributed to the collapse. The ground
supporting the scaffold was soggy from 3 inches of rain, and high winds had
caused further instability.
Lessons learned
This accident suggests several lessons learned involving the use of
scaffolds that can be applied to DOE construction sites:
-- Management and safety organizations are responsible for ensuring that
scaffolding is not modified in a manner that violates standards established by
OSHA and the American National Standards Institute. Modifications must be
based on thorough analysis by qualified engineers and must be implemented in a
manner such that minimum standards are maintained or enhanced.
-- Management and safety organizations are responsible for ensuring that
scaffolds are erected and used in the manner for which they were designed.
Supervisors should conduct frequent checks to determine that scaffolds are
safe, are used correctly, and are not overloaded with workers or material.
-- Workers and their supervisors should be trained in the proper use of
scaffolds. Training should provide workers with the capability to recognize
potentially unsafe conditions, such as those posed by inclement weather or
questionable structural modifications.
Management is responsible for implementing programs to educate workers
and supervisors about proper maintenance and safe work practices for the use
of scaffolds.
Five Recent Incidents:
DOE TRUCKBED AND TRAILER SAFETY
Truck and trailer accidents can occur under a variety of conditions.
Workers must be aware of safety requirements when operating, loading, or
parking trucks or trailers. This article discusses five incidents in which
trucks or trailers tipped over or lost a load because (1) their weight balance
was upset, (2) their load was improperly secured or moved, or (3) they were
parked on an unsuitable surface. In three of these incidents, the trailers
were stationary when they tipped.
Load shifts
On February 3, 1994, a subcontractor at Brookhaven National Laboratory
used a flatbed truck to move two 1,500-KVA transformers from a parking lot to
a nearby substation. As the truck left the parking lot, it overturned and the
transformers fell to the ground. The accident resulted in about $45,600 in
damages to each of the transformers and $5,000 in damages to the truck.
Investigators concluded that the truckbed was overloaded: although the
maximum load capacity was 18,500 pounds, the combined weight of the
transformers was 27,600 pounds.
In August 1993, an incident at the Oak Ridge Site occurred when four
zirconium oxide parts in cylindrical metal containers were being transported
on a flatbed truck from a dock to an adjacent building. Each container was
placed on a metal pallet. Welded steel plates (or "ears") were used to hold
the containers in place. Residual mineral oil from one container drained
through the pallets and onto the metal truckbed, creating a slick
metal-to-metal surface. As a result, the pallet and the container slid off
the truckbed. Used alone, the ratchet tie-down straps secured to the metal
bed were not sufficient to ensure the safety of the load.
Drill rig topples
In a similar incident, a cart used to transport a drill rig toppled.
This incident occurred in December 1993, when a subcontractor at the Kansas
City Plant was preparing to use a small, skid-mounted drill rig. The rig
weighed approximately 5,000 pounds, and the derrick stood 15 feet high when
raised to the vertical position.
The drill rig was moved to the work site on a specialized trailer (known
as a "transportation cart") with a 2-foot-high bed. To save time, the
operator decided not to remove the rig from the cart before beginning to
drill. When he positioned the heavy drill table at the rear of the rig, the
rig became unstable. The front wheels of the cart rose from the ground and
the cart pivoted on its rear wheels, causing the rig to tip over. The derrick
hit a nearby building. Damage to both the rig and the building was minimal,
and fortunately no one was hurt. The operation was stopped immediately: the
subcontractor was cited for using equipment in an improper manner and was
ordered to leave the site. An investigation conducted by the contractor found
that the drill rig operator had successfully completed several drillings
without incident. However, in this case, the operator attempted to save time
by leaving the rig on the cart.
Trailer landing gear sinks
The first of two incidents involving trailer landing gear occurred at
Savannah River Site in July 1993 and involved a 5,500-gallon tank trailer
filled with water. The tractor-trailer was parked in an area near a
maintenance building. The landing gear was lowered to support the front of
the trailer and the tractor was disconnected. After the tractor was moved
into the maintenance building, workers heard a loud noise. When they went to
the parking area, they discovered that the landing gear pads had sunk into the
asphalt, damaging the trailer and spilling the tankful of water.
The second incident occurred at Oak Ridge National Laboratory on January
10, 1994. The driver of a tractor pulling a tank trailer containing 3,000
gallons of process water had lowered the landing gear on the trailer. He then
disconnected the tractor from the trailer, and one of the trailer landing gear
pads sank into the asphalt, causing the tank trailer to roll over and down an
embankment. When the tank rolled over, it broke a power pole, requiring a
power shutdown while the tank was put upright and lifted back onto the road.
About $15,000 in damage was done to the trailer, and the entire 3,000-gallon
load of process water was lost. Because the process water contained 60
gallons of sulfuric acid, it had to be partly neutralized with sodium
hydroxide and diluted with about 10,000 gallons of mineralized water.
Investigations of these two incidents identified a common problem: the
surface areas where the trailers were parked were not strong enough to bear
the concentrated load. When the weight was placed on the landing gear pads,
the load-bearing capacity of the parking surface was exceeded.
Lessons learned
Awareness of the load and its content, weight, and physical placement on
the trailer are important components of transportation safety. The incidents
described in this article suggest the following lessons learned:
-- Ensure that workers are fully trained. Workers responsible for operating
trucks and trailers must learn how and where to park. For example, when a
trailer is parked on a surface other than concrete, the driver must be aware
that the surface may be too soft for the concentrated load exerted by the
landing gear pads. The driver should also look for cracks, uneven surfaces,
grass growing through the asphalt, or other signs of weakness. Heavy planking
or grillage can distribute the load more evenly, thus preventing the legs from
sinking into the parking surface.
-- Load vehicles properly. In the Brookhaven incident, the vehicle was
loaded without regard to its load capacity or the gross weight rating.
Contracts should require documented training programs for operators as part of
the scope of work. The subcontractor should have divided the load
appropriately for the vehicle or used two vehicles for the transport.
-- Secure loads properly. The load shift on the flatbed truck at Oak Ridge
resulted from the failure to use blocking. Because of the space left between
the skids, the nylon strapping lost its tension when the load shifted.
-- Observe established operating procedures. To do the job more quickly,
the drill rig operator deviated from procedures that called for the operator
to ensure that the rig was stable at all times. The drill rig should have been
removed from the transportation cart and placed on the ground to provide a
stable platform for drilling.
-- Learn from past problems. Management is responsible for identifying and
disseminating lessons learned. For example, if management at Oak Ridge had
been aware of the earlier instance of the landing gear sinking into the
asphalt at Savannah River, they could have taken steps to prevent recurrence.
OSHA regulations do not apply to these incidents. However, Department of
Transportation regulations, stipulated in 49 CFR 393.100 through 49 CFR
393.106, provide useful guidance. DOE 1540.1A, "Materials, Transportation,
and Traffic Management," also applies.
References CH-BH-BNL-PE-1994-0003; ORO--MMES-Y12SITE-1993-0041
ALO-KC-AS-KCP-1993-0033 SR--WSRC-CSWE-1993-0003 ORO--MMES-X10PLEQUIP-1994-0001