1、Public Lessons Learned Entry: 5996 Lesson Info: Lesson Number: 5996 Lesson Date: 2011-07-13 Submitting Organization: KSC Submitted by: Amber Porter Subject: Vehicle Assembly Building (VAB) Fall from the 41st Floor Abstract: An ironworker (IW2) fell approximately 12 feet from a fixed ladder to a smal
2、l platform below Level 41 in High Bay 4 of the VAB. In the process of falling, IW2 struck another ironworker (IW1), knocking IW1 from the lower platform into open space. A fall to the High Bay 4 floor approximately 450+ feet below was prevented by IW1s usage of personal fall protection equipment. Bo
3、th workers sustained non-life threatening injuries and received out-patient care. Description of Driving Event: On 23 October 2006 at approximately 9:50 a.m., an ironworker fell from a fixed ladder on the Level 41 north side of High Bay 4, knocking another ironworker from a 4-foot square lower platf
4、orm into open space. The first ironworker (IW1) descended a fixed ladder (without the use of fall protection), and was standing at the side of the base of the ladder, with one foot on the platform and the other foot on a structural beam waiting for ironworker 2 (IW2). After descending the ladder, IW
5、1 connected a fall protection lanyard to a pre-positioned rope grab that was attached to a 5/8-inch diameter nylon rope vertical lifeline. IW2s personal fall protection lanyard was connected directly to a steel ladder climbing device cable attached to the ladder. Earlier that morning, another ironwo
6、rker (IW3) decided the knot securing the lifeline to the ladder rung was insufficient, and added an additional half-hitch to the two existing knots. (It was undetermined whether the additional half-hitch prevented the knot from untying). As IW2 transitioned from the platform to the ladder, IW2s righ
7、t hand became entangled in tethers attached to the fall protection harness preventing a firm grasp of the ladder rung. IW2s left hand was not yet in contact with the ladder but IW2 continued in motion away from the platform to the ladder. IW2 fell and impacted IW1 who was standing on the small door
8、access platform approximately 12 feet below. As IW2 fell, IW1 alerted by the commotion, looked up, stepped forward and raised his arms. IW2 struck IW1 in the chest, knocking IW1 off the platform and beam. IW1s knee was injured in the impact with IW2, and IW2 sustained injuries as a result of impacti
9、ng the fixed structure including the platform, which was where IW2 came to rest. IW1s fall was arrested by personal fall protection equipment, and IW1 was suspended 450+ feet above the VAB floor. Lesson(s) Learned: When working in high altitudes, workers need to practice safety procedures by wearing
10、 their personal protective equipment in order to prevent accidents due to falling. Recommendation(s): Employees should be trained or retrained in tool control practices while working at heights, as well as ascending and descending ladders. The training should include that employees be prohibited fro
11、m having tool tethers attached to their fall protection harnesses while ascending and descending ladders. Fall protection should be used for fixed ladders less than 24-feet (20-feet for general industry), where the potential exists for a fall beyond the base of the ladder. NASA should ensure that co
12、ntractors require the proper use of fall protection for tasks exposing workers to falls from unprotected heights. Better coordination between NASA safety and NASA contracting is needed for identification and coverage of ongoing construction projects. Contractors should maintain training documentatio
13、n to ensure employee training is current for all potential tasks. The use of nylon rope lifelines should be avoided. However, when no other alternative exists, nylon rope should be used in a manner that will not weaken the rope, including the use of knots. NASA safety should attend contractor meetin
14、gs, and improve communications with all construction contractors and NASA procurement. NASA procurement should invite NASA safety to pre-bid walk-downs. That should provide NASA safety with information about where work will be performed. In addition, it will be useful for the safety planning process
15、 and for improving Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-communications between the organizations. Evidence of Recurrence Control Effectiveness: N/A Documents Related to Lesson: Click to View Mishap Report Mission Directorate(s): N/A Additi
16、onal Key Phrase(s): Program Management.Communications between different offices and contractor personnel Additional Categories.Human Factors Safety and Mission Assurance.Maintenance Additional Categories.Accident Investigation Additional Categories.Ground Operations 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-,-,-
