DZAC

June 2014

Injury Investigation Oak Ridge National Laboratory - March 31, 2014

Scattering Chamber

• Removed from service early 2000’s

• 1585 lbs.-65 inches tall• Purpose of the wheeled

cart was to permit adjustment of the equipment during experimental configuration-Not intended for transportation

Decision to Excess

• Excess Property Form indicated the assembly was “top-heavy” and that Riggers would need to transport

• Moving crew transported to the Excess Property Sales Warehouse

• Buyer purchased the unit and arrived to pick up the scattering chamber and other equipment

Buyers Truck/Loading Dock

• Two employees• 1 in front 1 behind• Slight incline 6.25%• Reached the transition

point between the loading ramp and the truck

• Fell on the employee in the path of travel

Overturned Scattering Chamber

Injuries

• Lower leg fractures• Broken thumb• Several Lacerations• Surgery required

Moving From Storage to Excess

• Move Crew Moved Item to Excess– 3 Laborers– 1 Driver

• Excess Property Form was affixed to the assembly• Last item loaded on the deliver truck-secured to the

left side of the truck with two straps– Form was not noticed– Movers did not recognize or consider high center of gravity– Wheels, smooth level path

Shifted During Transport to Excess

Shifted During Transport to Excess

• Stainless steel vacuum tube and flange punctured the wall of the delivery truck

• Two of the 4 wheels suspended in midair• One Mover used a sledge hammer to dislodge the

tube on from the wall of the truck• While two salvage handlers stood on the elevated

section of the cart using their combined weight to bring the scattering chamber into an upright position

What Went Wrong?

• Organizational Change-Supervisor and two Salvage Handlers were new to their positions

• 3 Experienced Salvage Handlers retired• A Salvage Handler call in sick and was replaced with a

Laborer• Excess Property Form is removed from the equipment

two –three days prior to sales-standard Practice• A premium was put on the timely and efficient loading

of vehicles

What Went Wrong?

• Salvage Handler activities were judged to be grade 4 their work plan was indicated as grade 3 – Incomplete execution of ISM and Laboratory safety

expectations of Grade 3 work• Work plan was not of sufficient detail to enable

comprehensive identification of hazards and assignment of controls– e.g. moving top heavy and potentially unstable

equipment

What Went Wrong?

• No records of proper lifting techniques training• No documented pre-job briefing• Moving crew pickup list does not include Excess

Property Forms information• Involvement of Riggers support is based on judgment

and experience-not weight

What Went Wrong?

• The Salvage Handler had no information-on weight, or stability of wheels

• Salvage Handler B did not communicate with Salvage Handler A-Movers did not communicate with Salvage Handler Supervisor

• Salvage Handlers choose to move the chamber down the ramp rather than move the truck to a larger door where they could have used a forklift

What Went Wrong

• Unsafe Behavior exhibited by Moving crew by standing on the base of the chamber

• Moving Crew and Salvage Handlers failed to notice the Excess Property Form hazard indications

• Potential risk of providing unstable item to a member of the public was unrecognized

Action Items

Issue Solution Location Reported Date CATS # Status RI

Traffic issues B 15-Ca government parking be put in

Employees advised to take pictures of cars/license plates and notify

cars/license plates/notify protective services/Mike Wisherop Site wide May-14 In progress

Mike Wisherop

B 48 Rocks fall on sidewalk Entered into CATS to find solution B 48 9-Apr-14 PendingTammy

Thompson

B 77 Possible unsafe work conditions Entered into cats to find solution B 77 9-Apr-14 9634 Pending

Tom Price/Safety

GroupToo many interviews for small injuries

Eliminate injury reviews for minor incidents 12-Mar-14 NA Resolved Janice Sexson

Too many injury interviews/per injury Track and resolve 12-Mar-14 NA In progress Janice SexsonFirst Aid kits not available First aids to be ordered Sitewide 12-Mar-14 NA Resolved Janice SexsonRock located on hill above B 48 Work order for engineer to evaluate B 48 12-Feb-14 NA Resolved Janice SexsonLocked PPE Supervisor will take over PPE Program B 76 12-Feb-14 NA Resolved Tom CaronnaTool Crib emergency equipment not available-when needed-borrowing from ALS

Email list of missing items to Kory Porter B78 12-Feb-14 NA Resolved Kory Porter

Employees can be struck by or blocked by vehicles parking in front of shop

Bollards to be installed in front of Plumbers shop B 78 January 8 2014 NA Resolved

Janice Sexson

DZAC Action Items

Round Table – June Homework

Best Practices– What is your work group doing “right”?– What are your work group’s“ Best Practices”?– How can we expand on those “Best Practices”?– Is Safety a value shared by everyone in your work

group?– Do you feel like you own safety?

July Homework

Chemicals• Do you know the hazards

and controls for all of the chemicals you work with?

• Do you and your coworkers know where to find your Safety Data Sheets?

• Do you have any questions about the chemicals necessary for your work?