REG NASA-LLIS-0940-2001 Lessons Learned 12 Foot Pressure Wind Tunnel Fall Mishap Report.pdf

1、Lessons Learned Entry: 0940Lesson Info:a71 Lesson Number: 0940a71 Lesson Date: 2001-06-18a71 Submitting Organization: ARCa71 Submitted by: Anthony BricenoSubject: 12 Foot Pressure Wind Tunnel Fall Mishap Report Description of Driving Event: An engineering technician was standing on a temporary platf

2、orm located between the guardrails of the 3rd floor and the exterior surface of the test section plenum. The platform did not inlcude guardrails or other fall restraint devices. The technician was threading a pipe assembly into a blind flange. The pipe assembly was necessary to route test-dependent

3、instrumentation wiring out of the plenum. While tightening the pipe assembly, the open-ended adjustable wrench he was using slipped off the pipe. This caused him to lose his balance and fall onto the curved exterior of the plenum at the 3rd floor level. He slid down the plenum surface approximately

4、25 feet to a metal obscuration platform located 40 inches below the surface of the 2nd level. The technician sustained a fractured left scapula, a severe laceration of his scalp, and a minor concussion. This injury resulted in several days away from work. Medical assistance was provided in a very ti

5、mely and effective manner by co-workers and medical personnel. This mishap occurred on December 14th, 2000. A mishap investigation board began its investigation of this mishap on December 15, 2000.Lesson(s) Learned: Fall protection must be used and enforced while working in locations which pose subs

6、tantial risk of a fall.Recommendation(s): 1. Ensure compliance with fall protection and working heights standard.2. Management to evaluate the need for a specific fall protection retraining interval.3. Use this incident as a lessons-learned exercise in fall protection training.4. The observation of

7、blatant or repeated violations of safety requirements must be addressed by managers and supervisors through consistently applied corrective and disciplinary actions.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-5. Organization to take steps to ensu

8、re that prior to proceeding with any work, every employee has the knowledge, tools, and equipment to complete the job safely.6. Managers/supervisors must continuously reinforce the safety principle that “whenever there is a conflict between our safety objectives and mission objectives, safety shall

9、be our first consideration“.7. Management shall provide easy access to all safety documentation for employees. When new information is distributed, an overview of the information should be provided through some form of interactive presentation such as branch meetings, toolbox discussions, etc.8. Mai

10、ntenance engineering should be incorporated in the requirements for facility design.9. All facilities that have the potential for fall hazard should be inspected for fall hazards within the next six months.10. Update AHB 1700.1 to correct errors in fall protection references. The Ames Safety Office

11、should prepare an additional chapter dedicated to this subject matter.11. The Ames Safety Office should evaluate the existing training records database for effectiveness in informing supervisors of their employees training history and requirements.12. The Ames Safety Office should provide training o

12、r professional assistance to employees and their supervisors on hazard identification for their areas of control.13. Inspectors who conduct periodic safety inspections should have adequate expertise and training to be able to identify existing hazardous conditions in the workplace.Evidence of Recurr

13、ence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Administration/Organizationa71 Environmenta71 Facilitiesa71 Ground Operationsa71 Ground Equipmenta71 Hardwarea71 Human Resources & Educa

14、tionProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Occupational Healtha71 Safety & Mission Assurancea71 Test FacilityAdditional Info: Approval Info: a71 Approval Date: 2001-06-26a71 Approval Name: Eric Raynora71 Approval Organization: QSa71 Approval Phone Number: 202-358-4738Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-