Safety Update

Recent Injuries

May 5, 2009

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

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During the second quarter of fiscal year 2009, we had two injuries resulting from falls. Both involved medical treatment and both resulted, at least in part, from inadequate equipment. A brief summary of each follows.

The first injury involved a user who fell from a ladder stand and cut his lip. He was evaluated at the BNL Occupational Medicine Clinic and then referred to an off-site physician office where he received several sutures. He returned to work the following day and, although painful, this injury was minor with no significant work absence and no permanent medical concern. However, it is easy to imagine how this event could have been much worse.

The user was working at a beamline end station installing a detector above an optical table. The task is somewhat awkward and requires two people. Both work on a step stool or step ladder stand to reach the equipment and the task requires both people to lean forward slightly. The injury occurred when the ladder stand being used slipped and the user lost his balance and fell. Subsequent analysis showed that use of the equipment is a reasonable and acceptable approach to completing this task. Personnel are not too high, the slight lean required is not excessive, and the equipment installed can be managed with two people. So, what went wrong? Two of the four legs of the ladder stand had no skid protection. The rubber "feet" were missing so the stand slipped. What else went wrong? This is a routine task completed often with the same or similar equipment. No one recognized that the ladder stand skid protection was missing or important. The step stool used also had no skid protection.

The second injury involved a staff member who momentarily lost his balance while working from a ladder. He hurt his arm and surgery was required for treatment. There was some loss of work time. Physical therapy is ongoing and everyone is hopeful that the injured arm will return to full strength and function.

The injured staff member was working on a ladder that was supported by a second staff member. The injury occurred when the worker turned slightly on the ladder and lost his balance. He was able to catch himself before falling, but strained his arm as a result of that effort. Subsequent evaluation indicated that this use of a ladder was acceptable for the task: the ladder was found in good working condition, and the worker is qualified and practiced in ladder use. What went wrong here? Some inattention to detail in maintaining good control on the ladder contributed, but also, the ladder chosen is inadequate. It is a Type III ladder rated for household use with a load capacity of only 200 pounds. That type of ladder twists easily and is less stable than other more robust ladders. That lack of stability may have contributed to the injury.

Most of us have been to the recent Human Performance discussions and learned about error precursors and finding situations that can lead to injury before those injuries occur. We learned that we cannot stop people from making mistakes, but can find and control the circumstance that led to those mistakes. Both these injuries provide good lessons. After the ladder stand injury, personnel toured NSLS facilities and found 156 step stools; 112 had no skid protection. On the same tour, 40 ladder stands were found; 15 had one or more rubber feet missing. People must have slipped on these many broken step stools and stands and so could have recognized and acted on this issue. After the ladder injury, a tour of NSLS facilities found two additional Type III ladders. BNL training identifies the limitation of Type III ladders. Someone also could have recognized and acted to eliminate this risk.

People who study Human Performance tell us that to achieve zero injuries, we have to evaluate work areas and tasks knowing that mistakes will be made and we must find the circumstances that can trigger those mistakes or turn an error into an injury. Overlooking the items described above is easy to understand and looking back now makes them far easier to identify. The challenge is to find one before an event. The problem identified need not be complicated. Just noticing something as simple as a missing rubber foot on a stand or a missing rubber ring on a step stool can help.