REG NASA-LLIS-5216-2011 Lessons Learned Pre-Task briefings to Improve Safety Ladder Fall Incident.pdf

1、Public Lessons Learned Entry: 5216 Lesson Info: Lesson Number: 5216 Submitting Organization: KSC Submitted by: Dawn Martin Subject: Pre-Task briefings to Improve Safety / Ladder Fall Incident Abstract: A technician climbed a five-foot portable ladder to the second-from-the-bottom rung in preparation

2、 for a cable pulling task. The technician moved a ceiling tile in order to view the area above the ceiling. After finishing the inspection of the above-the-ceiling area, the technician began descending the ladder. The technicians right boot momentarily caught at the second-from-the-bottom rung. This

3、 caused the technician to pivot counterclockwise (plan view), twist away from the ladder, and fall approximately two-feet to the vinyl-asbestos tile covered concrete floor. The technician suffered injuries in the form of a laceration to his/her forehead and a broken arm. Pre-task briefings should be

4、 conducted to raise awareness of possible safety problems and proper techniques. Description of Driving Event: A technician climbed a five-foot portable ladder to the second-from-the-bottom rung in preparation for a cable pulling task at the Operations and Checkout building (O&C), at approximately 9

5、25 a.m. on June 17th, 2007. The task that the Technician was completing at the time of the mishap was in preparation for the cable pulling portion of Work Order (WO) 474304 “Install (2) Aggregate Switches in the O&C”. Prior to pulling the cable, the Technician determined it was necessary, based on

6、prior experience in the O&C Building, to verify that the routing path for the cable was clear of obstructions. To complete this task, the Technician had to remove a ceiling tile and look up into the area above the ceiling. Reaching the ceiling tile required the use of a ladder. The technician moved

7、a ceiling tile in order to view the area above the ceiling. After finishing the inspection of the above-the-ceiling area, the technician began descending the ladder. While descending, the technician held the ladder side rail with his/her right hand only. The technician stepped down one rung with his

8、/her left foot, then, while attempting to slide his/her right foot off the second-from-the-bottom rung, the technicians right boot momentarily caught at the second-from-the-bottom rung. This caused the technician to pivot counterclockwise (plan view), twist away from the ladder, and fall approximate

9、ly two-feet to the vinyl-asbestos tile covered concrete floor. The technician suffered injuries in the form of a laceration to his/her forehead and a broken arm. Pre-task briefings should be conducted to raise awareness of possible safety problems and proper techniques. Provided by IHSNot for Resale

10、No reproduction or networking permitted without license from IHS-,-,-Figure 1: Technician 1s right boot gets caught in the second-from-the-bottom rung of the ladder Lesson(s) Learned: KICS Management did not have an established process for training personnel on conducting pre-task briefings. KICS Sa

11、fety failed to ensure implementation of COMM-P-137, Pre-Task and Pre-Test Briefings, as required by COMM-P-137, section 4.4.2. Field Service Specialist training on COMM-P-137 is limited to how to access COMM-P-137 on the computer. KICS Management failed to develop Job Safety Analysis and therefore f

12、ailed to comply with the policies and requirements identified in COMM-P-149, Job Safety Analysis, section 4.1.2. Recommendation(s): 1. Special attention should be given to inform personnel about the possibility of snagging footwear while climbing. 2. Ensure that technicians understand and use Three-

13、Point Contact when climbing ladders, change KICS Three-Point Contact requirements to match OSHAs interpretation. 3. Pre-task briefings should be conducted to raise awareness of possible safety problems and proper techniques. Evidence of Recurrence Control Effectiveness: N/A Documents Related to Less

14、on: COMM-P-137, Pre-Task and Pre-Task Test Briefings COMM-P-149, Job Safety Analysis Mission Directorate(s): Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Space Operations Additional Key Phrase(s): Industrial Operations Risk Management/Assessment Planning of safety systems Facilities Industrial Operations Additional Info: Project: N/A Approval Info: Approval Date: 2011-03-21 Approval Name: mbell Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-