Safety Update

Injuries at the NSLS

October 1, 2007

Andrew Ackerman
NSLS ESH/Q Manager
ackerman@bnl.gov

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There have been five injuries at the NSLS during fiscal year 2007. Three were classified as first aid cases and two were considered "recordable." First aid cases involve only cursory treatment such as a bandage or a suggestion that the patient take some "over-the-counter" medications. Recordable cases involve more treatment or prescription medication, and a subset of recordable cases includes more severe workplace injuries or illnesses that result in lost work time, work restrictions, or transfer to a different job. These are called "DART" cases, an acronym for "Days Away, Restricted, or Transferred." There were no DART cases at the NSLS during FY '07, '06, or '05.

The five injuries that occurred this fiscal year are worth noting, as it is important that everyone is aware of this issue to learn any lessons presented. Each occurrence involves individual circumstances, but all of them are the kind of injuries that can happen anywhere. Some details follow.

The three first aid cases of FY '07 are: a cut finger while working on an electronics rack, a bumped finger while moving a compressed gas cylinder, and a bumped finger while disassembling a beamline component. None of these injuries were serious, and although the gas cylinder and beamline injuries are not likely to happen at home, they are examples of loss of control while working with heavy objects and so are the kind of injury that can happen anywhere. As we investigated each of these incidents, we found that these events, except for the beamline disassembly, are not the result of poor planning; they are more the result of some bad luck and perhaps some inattention to detail.

Luck and attention to detail contributed to the beamline injury, but other important contributing factors included the evolution of the line with changes in staffing over time and a lack of thoughtful design. This incident involved the removal of supports that appeared to anchor only a component of a larger chamber, but that actually also supported the chamber itself. When the supports were unfastened, the chamber suddenly dropped 3-4 centimeters and banged, but did not crush, the hand of the worker. This event reminded us that most lines are now staffed by personnel who were not involved with the original building of the line and so do not necessarily know every detail of construction. In this particular case, the design of the chamber that shifted unexpectedly was not as thoughtful as it could have been. One lesson here is to recognize that many beamlines predate the present personnel and so some extra care is needed, and help from others might be warranted. Another lesson focuses on design. While devices must meet function requirements, they also must be user friendly. We have updated our design review documentation to include attention to support mechanisms and elimination of hazards such as pinch points when possible. These, and other "Human Factors" issues are important design considerations. The beamline injury was minor, but the forces involved were significant, and the result of the chamber position shift could have been much worse.

The two recordable cases this fiscal year are a fall down the stairs and a bumped elbow that occurred while moving material through a doorway. Again, these injuries did not result in loss of work, but were more severe than the others. These injuries could happen anywhere and, like the first aid cases, are not so much the result of poor planning.

So, what are the lessons to learn here? The beamline injury lessons are discussed above. From investigation of the other injuries, we see the importance of constant attention to detail and avoiding distraction. Assuring that everyone knows about these incidents is another good idea as a way to keep attention on this issue, and I hope this article will help. These common life injuries are happening at the NSLS and across BNL and while they may seem trivial, they are not. We have to be attentive to the everyday tasks we do and recognize that injury can result from these simple actions. That awareness is our best hope for eliminating these events.

Andrew Ackerman
ESH/Q Manager