REG NASA-LLIS-5877-2012 Lessons Learned - Thumb Amputation with Magnet at Reutilization Recycling and Marketing (Bldg M6-1671).pdf

1、Public Lessons Learned Entry: 5877 Lesson Info: Lesson Number: 5877 Lesson Date: 2011-06-21 Submitting Organization: KSC Submitted by: Amber Porter Subject: Thumb Amputation with Magnet at Reutilization, Recycling, and Marketing (Bldg. M6-1671) Abstract: An employee at the Property Disposal Facility

2、 decided to remove two magnets attached to a core element identified as scrap metal. The magnets collided together severing a portion of the right thumb at the first joint. Description of Driving Event: On June 7, 2010 the IP, an employee of a subcontractor, working at Building M6-1671/Property Disp

3、osal Facility, located on Ransom Road, severed a portion of the right thumb when two high powered magnets collided with each other. At the time of the mishap, the Injured Person (IP) was in-checking material identified as scrap metal and decided to remove two magnets attached to a discarded prototyp

4、e Multiple Gas Analyzer (MGA) chassis identified as scrap. The IP removed Magnet 1 and attached it to an industrial steel shelving unit for staging. The IP then detached Magnet 2. While attempting to stage Magnet 2 to the shelving unit, the magnets collided together severing a portion of the IPs rig

5、ht thumb at the first joint. Lesson(s) Learned: Employees need to continually be aware of the potential danger of disassembling hardware during decommissioning and be knowledgeable of safety procedures when handling high powered magnets. Recommendation(s): Require end item users to identify high pow

6、ered magnets as dangerous when transporting or storing them outside their operational configuration or during the excess process. Identify the potential danger of disassembling hardware during decommissioning Update policies, procedures, or processes for excessing prototype hardware so that emphasis

7、 is placed on hazards. Evidence of Recurrence Control Effectiveness: N/A Documents Related to Lesson: Click to view mishap report Mission Directorate(s): N/A Additional Key Phrase(s): Safety and Mission Assurance.Maintenance Additional Categories.Human Factors Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Additional Info: Project: N/A Approval Info: Approval Date: 2012-05-09 Approval Name: mbell Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-