EH-9412 December 1994 Occupational Safety Observer
December 1994, Vol. 3 / No. 12
In This Issue
Flying Post Shatters Window ........................... 1
Another Scissors Lift Topples ......................... 2
Fires Interrupt Roof Repairs .......................... 4
Snapped Rigging Cable Cracks Window ................... 5
Routine Metal Cutting Ignites Fires ................... 6
Carbon Monoxide Poisoning ............................. 7
From the Deputy Assistant Secretary
Season's greetings! I hope this newsletter finds you and your family safe
and in good health.
As we stated in our first issue, the purpose of the Occupational Safety and
Health Observer is to raise the awareness of the DOE community about
occupational safety. As we enter our third year, our scope has been expanded
to include articles about all aspects of occupational safety and health.
Throughout this process, it has been my pleasure to participate in the
Observer's efforts to be more responsive to the needs of our readers. We are
grateful for your comments and suggestions, which have been and continue to be
crucial to our success.
Hazard Recognition
Flying Post Shatters Window
In September 1994, a backhoe operator at the Idaho National Engineering
Laboratory tried to remove a 12 x 12-inch post by hooking it near ground level
with one tooth of the backhoe bucket. When the operator raised the bucket,
the post came out of the ground abruptly and swung around, hitting the cab of
the backhoe. The windshield shattered, and one end of the post landed in the
operator's lap. Fortunately, no injuries resulted.
The Investigation
Investigators attributed this incident to poor planning and lack of hazard
recognition. Specifically, a job that included a number of unknown factors was
treated as a routine task. No drawings of the post installation were
available, and the depth of the post was unknown.
The group assigned to this job had routinely removed items such as 4 x
4-inch fenceposts and stop signs, but had no experience with a post of this
size. Another organization at the site was responsible for removing telephone
poles and had specialized equipment required for that type of job.
Responsibility for posts like the one involved in this incident, however, had
not been clearly identified.
The post, composed of very solid wood, was 15 feet long, extending 6 feet
below ground level. Although it had been in the ground since 1938, it showed
few signs of deterioration. When the backhoe operator attempted to remove the
post, he pushed a bucket tooth into it at a point below its center of gravity.
He then attempted to raise the bucket. Because the post was very heavy and
solidly embedded, the operator had to apply extra power to raise both the
bucket and the attached post. As a result, the post came out of the ground
more abruptly than expected.
Lessons Learned
As demonstrated by this incident, no job should be considered "routine,"
especially when unknown factors are involved. In this instance, there was no
documentation on the post; no one knew how much of the post was below ground
level, and no one knew how much force would be required to remove it.
Important lessons associated with this incident include the following.
All aspects of a task should be considered by everyone involved--no matter
how routine the task may seem. If anything is out of the ordinary, if anyone
doesn't have the appropriate experience, or if suitable equipment is not
available, the job shouldn't be approved or attempted.
A work plan should be developed to assign appropriate equipment and
properly trained personnel to perform each task. In this instance, the
planner didn't have detailed knowledge of the job or didn't recognize the
potential hazards.
Supervisors and planners should routinely visit work sites, asking
questions about potential hazards.
Reference
ID--EGG-CFALL-1994-0008; Joseph E. Fitzgerald, Jr., Deputy Assistant
Secretary, Safety and Quality Assurance
Work Coordination
Another Scissors Lift Topples
An article in the October 1994 issue of the Observer described an incident
at the Kansas City Plant involving a scissors lift that toppled while workers
were lowering a heavy load. A similar incident occurred recently at the
Weldon Spring Site Remedial Action Project in St. Charles, Missouri.
The Incident
On September 7, 1994, eight workers at the Weldon Spring Site were involved
in decontamination activities inside a room that measures 80 x 168 x 16
feet. Two workers were on a scissors lift, using it as a platform for
pressure-washing the ceiling, and another was using a Bobcat (a front-end
loader) to clean up debris. All eight wore full-face respirators.
Scissors lifts and Bobcats were often used simultaneously in the room. On
this occasion, however, the scissors lift and the Bobcat were operating closer
together than usual. The Bobcat driver snagged the pressure washer's hose,
which was tied to the scissors lift's railing, and the lift toppled. The two
workers on the scissors lift were secured with safety lanyards and fell with
the lift when it toppled 8 feet to the concrete floor.
At the time of the accident, no worker in the room had a radio to summon
help. A supervisor outside the room radioed for assistance from the site
emergency response team. One of the workers on the lift was more seriously
injured than the other. He was checked for contamination and removed from the
building. Paramedics determined that his injuries were potentially severe.
After being transported to a hospital by helicopter, the worker was diagnosed
with fractures to his jaw and wrist. The other worker sustained a sprained
and stress-fractured right elbow.
The Investigation
The site conducted a Type C investigation into the accident. Investigators
found deficiencies related to job coordination and scheduling. For example,
the Bobcat driver and the workers on the scissors lift should not have been
working so close to each other. (The Bobcat was only 8-10 feet from the
scissors lift.) Workers were also somewhat complacent about the hazards
associated with their work--Bobcat drivers were apparently accustomed to
driving over hoses as they worked. Investigators noted that the incident could
have been prevented if a breakaway fitting had been used to secure the hose to
the scissors lift. Finally, workers would have been able to summon help more
quickly if a radio had been in the room, although there is no evidence that
this delay contributed to the seriousness of the incident.
Investigators determined that these conditions violated OSHA regulations
specified in 29 CFR 1926.21(b)(2), which states that employers "shall instruct
each employee in the recognition and avoidance of unsafe working conditions."
Regulations covering elevated work platforms are listed in 29 CFR 1910.67.
Lessons Learned
These findings suggest several lessons learned, including the following:
o Supervisors and safety professionals should visit work areas routinely to
ensure that potentially unsafe conditions and practices are identified and
corrected.
o Proper work scheduling and job coordination are often crucial to safety.
Ensure that tasks performed in the same area do not interfere with each other.
o Good housekeeping is crucial to safety. Don't allow cables, hoses, and
lines to interfere with other workers. When necessary, securely tape these
items to the ground or mark them with flags so they won't constitute a hazard
for workers and moving equipment.
o Plan ahead to avoid potential problems. If you're routing a hose, line,
or cable, consider what will happen in the event of a snag. Use breakaway
fittings or slipknots, as necessary.
o Management must train workers to look for potential hazards in the
workplace. In this case, workers became complacent about driving a Bobcat
over hoses.
o Radio communication can save valuable time during an emergency. A radio
or other means of summoning help should be available at every job site.
Reference
ORO--MK-WSSRAP-1994-0039
Three Recent Events
Fires Interrupt Roof Repairs
Three recent fires at DOE facilities suggest the need for greater
sensitivity to fire safety during roof repairs--including pre-job hazard
identification and communication, control of the job site, and rigorous
compliance with established safety requirements--to reduce the risk of fire
and the damage it can cause.
The Incidents
The first fire occurred on August 15, 1994, when maintenance personnel were
heating synthetic tar in a portable kettle to repair the roof of a maintenance
shop at Hanford Site. A worker draining tar from the kettle into a bucket
noticed that the surface of the tar had caught fire in the bucket. As he
moved backward, the handle stuck to his glove and the bucket tipped over,
spilling the burning tar on the ground. The spigot on the kettle did not
close as designed, allowing additional hot tar to drain and causing the fire
to spread. The fire engulfed the tar kettle trailer and an adjacent utility
trailer that held a 25-gallon liquified petroleum gas (LPG) tank. When the
LPG tank exploded, the end cap was hurled about 130 feet, causing a small
grass fire. A second LPG tank in the vicinity vented but did not explode.
One worker sustained first-degree burns to his forearm from splattered tar.
The Hanford Fire Department was called to the scene to extinguish the fire.
Damage amounted to the total loss of the tar kettle, the adjacent utility
trailer, and the two 25-gallon LPG tanks.
A second incident occurred at Hanford on September 9, 1994. In this
instance, contractor employees were applying a polyurethane foam and a
silicone finish to the roof of a vacant building. Shortly after workers
applied a perimeter coating of silicone, a spark from a nearby welding
operation ignited vapor from the coating. A worker immediately used a fire
extinguisher to put out the fire. The site superintendent and the fire
department were notified, but further assistance was not required. The
damaged section of roof was repaired the same day, and all welding activities
were suspended until work on the roof was completed.
The third incident occurred at Savannah River Site on September 26, 1994.
After discovering a nest of ants while replacing a roof section, a contractor
employee poured a small amount of gasoline on the nest. Later that morning,
sparks from a grinding operation on the roof ignited the gasoline residue.
Workers on the scene quickly extinguished the small fire, with no visible
damage to the roof.
The Investigations
The two Hanford incidents were investigated as part of a larger Type B
accident investigation of fires. The results indicated a general lack of
attention to fire safety, although other safety issues received considerable
emphasis. Investigators identified several examples of how the breakdown of
either management processes or personal accountability contributed to these
incidents:
o Failure to conduct job safety analyses that would adequately identify
fire hazards;
o Failure to ensure that all hazards were communicated to personnel through
pre-job safety briefings; and
o Failure to verify that applicable fire safety requirements were
established and enforced (e.g., procedures related to proper orientation of
LPG tanks, housekeeping, and obtaining cutting-welding permits).
Similarly, the worker at Savannah River used gasoline, a hazardous
material, in a manner that violated site and contractor safety procedures.
Further, supervisors at the scene didn't ensure that appropriate barriers were
in place to limit access to hazardous materials at the work site.
Lessons Learned
Management should make certain that the following steps are taken to
prevent or control fires associated with roof fires.
o Identify and communicate all potential hazards before work begins. This
process is particularly important when unseen hazards exist, such as the
presence of flammable vapors. Precautions to ensure that materials do not
reach their flashpoints should be planned and executed. All required
thermometers, thermostats, and other safety devices for heating equipment
should be routinely inspected by qualified personnel.
o Control hazardous materials on the job site, including coordination of
concurrent work so that hazards are recognized and minimized. Ensure that
nearby workers are not exposed to hazards. Gasoline should not be used for any
purpose other than as a fuel.
o Develop fire protection plans that will minimize the potential for roof
fires and ensure their control. Plans for responding to potential roof fires
should include controlling a fire to prevent its spread to other areas.
References
RL--WHC-KHCMAINT-1994-0011
RL--WHC-KHCONST-1994-0021
SR--WSRC-S247-1994-0016
Driver Uninjured
Snapped Rigging Cable Cracks Window
On September 15, 1994, a rigging cable snapped while a pump was being
pulled from a large storage container at Fernald. The cable struck and broke
the window of the forklift used to power the operation. Fortunately, no
further damage or injuries occurred.
The Incident
A truck driver had been assigned to assist a team of radiological control
technicians in unloading the container after a previous attempt had failed.
When the driver arrived on the scene, he noticed a half-inch steel cable. The
driver got a synthetic sling from the maintenance shop, and workers rigged the
cable and sling to lift the contents of the container. A radiological control
technician attached the sling to the pump and attached the other end to a hook
connected to the cable. The technician attached the cable to a double
thickness of barrel strap, which in turn was connected to the mast of the
forklift.
After the workers attached the cables, the driver backed up the forklift
about 3-4 feet, pulling the pump until it got stuck on excess material in the
container. After the forklift moved about one more foot, the cable snapped and
flew through the air, striking and cracking the window.
Causes
A review by workers and supervisors identified several factors that
contributed to this incident. First, unqualified personnel and improper
equipment were used to unload the pump. A millwright trained in rigging
practices should have rigged the cables--not a truck driver and a crew of
radiological control technicians. The cables used and the manner in which
they were rigged were not appropriate for the task. In addition, the
supervisor in charge failed to identify the personnel and equipment required
to perform the task safely.
Although the workers involved were well-intentioned in their efforts to get
the job done, they risked their own safety by not preparing a pre-job plan and
by performing a task that was beyond their areas of expertise. Workers and
supervisors alike focused on task completion. In doing so, they ignored
standard safety practices, failing to analyze the task at hand or to determine
the safest way to perform that task.
Lessons Learned
The two major lessons learned stem directly from the causes of the
incident:
o First, workers should never be assigned to perform tasks for which they
are not qualified.
o Second, safety in the workplace can be facilitated by using trained
personnel and appropriate tools.
Supervisors are responsible for observing job performance and providing
specific instructions about who should do a job and what equipment should be
used. Taking the time to plan a job--and allowing time to complete it
safely--can prevent close calls and serious injuries.
Reference
ORO--FERM-FEMP-1994-0067
Cutting and Welding
Routine Metal Cutting Ignites Fires
Two fires at separate DOE facilities were recently caused by routine
metal-cutting operations. In both instances, acetylene torches were used to
cut holes in thick metal. One fire started during installation of an elevator
at the DOE Albuquerque Operations Office (AL). The second occurred at Idaho
National Engineering Laboratory (INEL) while welders were cutting apart a
12,000-gallon fuel tank.
The Fires
The AL fire occurred when a construction contractor was removing an
existing freight elevator to install a new passenger elevator in its place.
During the process, a metal plate with predrilled holes was to be installed.
Because the predrilled holes did not line up properly, the contractor had to
cut new holes using an acetylene torch. No hot-work permit was obtained for
this modification, nor were safety personnel notified that a welding operation
would be conducted.
When the cutting job had been completed, a worker posted as fire watch
heard a hissing sound. He discovered that stray hot slag had fallen near the
oxygen supply line. This line was located well beyond the area where slag
would be expected to fall. The fire watch grabbed the line with a gloved hand
to cover the leak. At this point, the oxygen supply line ignited with a
flash, causing second-degree burns to the worker's hand. When other workers
shut off the oxygen supply to the tanks, the fire subsided. The injured
worker was taken immediately to the health unit, then to a local hospital for
treatment. Safety personnel were promptly notified, and work on the project
was stopped until an investigation could be completed.
The INEL fire occurred while workers were using acetylene torches to cut up
a diesel fuel tank for disposal. The work plan called for the 12,000-gallon
tank to be cut lengthwise. After the top half of the tank had been removed,
the welders cut four holes in the bottom so the tank could be picked up and
moved. The bottom of the tank contained dried-up fuel sludge. Sludge is not
a hazard under normal conditions, but under the extreme heat of cutting
operations, it will ignite. In this instance, a piece of slag fell and
ignited the sludge. Workers attempted to smother the fire using hand-held
fire extinguishers. When this effort failed, the fire department was called
and the blaze was quickly brought under control. No damage or injuries
resulted.
The day after the incident, all contractor and subcontractor personnel were
briefed on the necessity of watching all areas where hot slag might fall.
Lessons Learned
These fires suggest several precautions to be taken during cutting and
welding operations.
o Management must ensure that safety procedures are adequate and that
contractors and subcontractors know and follow those procedures.
o Because slag can fall outside of the normal working area, it should
always be considered a fire risk.
o Using hot methods to cut fuel tanks is inherently a poor idea. Several
cold-cutting methods are available that do not create a fire hazard (e.g.,
using a shearing device--such as a guillotine--or drilling).
o If it's determined that a hot-cutting method is appropriate, two
precautionary options should be considered: purging the tank with hot steam
or covering any residue in the tank with fire suppressant foam before cutting
begins.
o Managers must ensure that lessons learned are available at all personnel
levels. INEL supervisors discovered after the fact that similar cutting fires
had occurred at their facility during previous months. The lessons learned
reports were being circulated at the management level, but not among the
workers.
References
ALO--GOAL-ALMSD-1994-0004
ID--MKF-MKEM-1994-0007
L.A. Accident Kills Three
Carbon Monoxide Poisoning
Carbon monoxide is a colorless, odorless, tasteless, and highly poisonous
gas. According to the National Safety Council, most of the 700 Americans
killed by poisonous gases and vapors in 1992 were killed by carbon monoxide.
A recent tragedy calls attention to the danger presented by carbon
monoxide. On the morning of Sunday, November 20, 1994, a family of five in
Los Angeles, California, was preparing to go to church. At 5:30 a.m., the
father went into the garage, which was attached to the house, and started the
family van. He did not open the garage door and left the door between the
garage and the house open.
More than an hour later, the fire department responded to an alarm from the
house. They found the father and his two sons in the house, dead of carbon
monoxide poisoning. The wife and daughter were taken to the hospital and put
on life support. The van, which was still running, had generated enough heat
in the enclosed garage to trigger a sprinkler system, which in turn had
activated the alarm.
Carbon monoxide is generated by incomplete combustion of materials
containing carbon. Wood, natural gas, fuel oil, and gasoline all generate
carbon monoxide when they burn. Carbon monoxide interferes with the ability
of blood to carry oxygen. A victim of carbon monoxide poisoning will begin to
feel drowsy and may not realize the immediate danger.
Vehicle engines and furnaces are common sources of carbon monoxide. To
lessen the risk of carbon monoxide poisoning from these sources, observe
sensible precautions like those provided in the checklist below.
Safety Tips to Prevent Carbon Monoxide Poisoning
o Verify that vehicles are in good mechanical condition. Have the fuel
system inspected by a trained technician to determine that the exhaust system
is intact and free of leaks.
o Ensure that vehicle interiors are sealed from exhaust.
o Always use the specified fuel for each vehicle.
o Never allow a vehicle to idle in an enclosed area or near the air intake
for a building.
o Inspect oil and natural gas furnaces regularly to ensure that they are in
good mechanical condition.
o Install carbon monoxide warning devices in buildings_especially in the
bedrooms of your home.
Accident Investigation Guide Available
Practical Guidance for Accident Investigation and Reporting is a 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.
Wanted: Authors and Articles
The articles you write, the topics you suggest, the questions you pose, and
your letters to the editor combine to make the Observer a timely, relevant,
and informative newsletter.
Our staff values your contributions. If you would like to submit an
article for publication consideration, please contact:
Coordinating Editor, Operations Management Division
(EH-321), U.S. Department of Energy; Telephone: (301) 903-2033.
A style sheet for authors is available on request.
To receive the Occupational Safety and Health Observer, telephone (206)
528-3552 or fax (206) 528-3554.
The descriptions of the incidents included in this compendium are based on
information available at the time of publication. Articles regarding DOE
incidents are drawn from Occurrence Reporting and Processing System (ORPS)
reports, accident investigation reports, and interviews with site personnel.
DOE 5483.1A, dated June 1983, requires DOE compliance with the OSHA
regulations cited.
If you would like more information about an article in this issue, have a
correction for an article, or would like to submit an article, please contact
the coordinating editor at:
Operations Management Division, (EH-321), U.S. Department of Energy;
Telephone: (301) 903-2033.
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