REG NASA-LLIS-1088--1992 Lessons Learned - ARC Table Saw Mishap Investigation Board Report of March 9 1992.pdf

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1、Lessons Learned Entry: 1088Lesson Info:a71 Lesson Number: 1088a71 Lesson Date: 1992-03-09a71 Submitting Organization: ARCa71 Submitted by: Peter J. Haro / Eric RaynorSubject: ARC Table Saw Mishap Investigation Board Report of March 9, 1992 Description of Driving Event: On Thursday, January 30, 1992,

2、 a NASA contractor employee was tasked by his supervisor with putting casters on a number of office chairs for the Flight Systems and Simulation Research Division Office. The contractor employee had already cut approximately three inches off each chair leg. Since it was not possible to mount the cas

3、ters directly to the legs of the chair, he was cutting small blocks of oak wood to attach the casters. The blocks then could be attached to the legs of the chair. At approximately 15:15 hours, the contractor employee was cutting the small wooden blocks (approximately three-fourths by three and one-h

4、alf by four inches) using a Government-owned Rockwell Delta ten-inch Unisaw (table saw), Model and Serial No.s 34-450 and GE 7834 respectively, located in the shop area of N243. The employee was cutting approximately one-sixteenth of an inch off each block to custom fit to each leg. He had set the b

5、lade height to approximately three inches. As he was pushing the fourth, and final, block through the blade path with his right hand, the wood block was rejected by the saw blade. This reaction pushed his hand into the blade. The employee severed two fingers (ring finger and middle finger) and fract

6、ured the bone and severed the tendon of the index finger of his right hand. The two fingers were severed between the first and second knuckles.Three of the employees co-workers responded; 911 was called at 15:20 hours and first aid was administered. One of the co-workers is a member of DART and he i

7、mmediately took command of the situation. He administered first aid, stabilized the injured employee and gave directions to properly secure and package the severed fingers. The Moffett Field Fire Department was called at 151:21 hours; they responded within three to four minutes of the emergency call

8、 from the Ames Duty Office; the time was approximately 15:25 hours. First aid continued and oxygen was administered until an ambulance responded at 15:32 hours (approximately 12 minutes from the time 911 was called) to take the injured employee to the hospital for further treatment. The Emergency Ro

9、om Physician was able to save the index finger, but advised him that due to the excessive skin and bone damage, his ring and middle fingers could not be reattached. The Emergency Room Physician Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-commende

10、d the efforts made in preserving the severed fingers. The injured employee was released from the hospital that evening at approximately 19:30 hours.A review of the contract under which this person was working was conducted with the Contracting Officer and an inspection of the accident site and the t

11、able saw was performed. Three experts on use of wood saws were consulted and one equipment maintenance individual was utilized to evaluate the condition of the table saw. A review of the Centers accident response system was conducted, consisting of the Duty Office, the 911 system, the ARC Health Uni

12、t, the Moffett Field Fire Department and the Bay Area ambulance service.Lesson(s) Learned: 1. Simple formal or informal refresher courses on the proper use of equipment at regular intervals may help to prevent this type of accident. Shop equipment is located throughout the entire ARC facility and is

13、 necessary for day-to-day activities. Some of that equipment is used infrequently. Operators that receive training or guidance on a regular basis will keep their skills up to par.2. The fact that the health unit doctor did not respond to this particular accident probably did not affect the outcome i

14、n any way. However, the perception that a doctor was available and did not respond should be addressed. Just the presence of a doctor in an emergency situation has a calming effect on injured parties and their coworkers. The health unit should respond to all medical emergencies while they are on cal

15、l.3. Contractors need to work within the purview of their contracts. Organizational Directors should participate with civil servant contracting staff to accomplish this objective.4. Many areas throughout ARC are still not equipped with proper first aid equipment. Updated kits are available through A

16、RC stores stock. Area supervisors should evaluate which kits would be the most appropriate and accordance with Code DQH to make them available.5. With those accidents that are major, it is imperative that the accident scene be preserved as soon after the accident as is practical. The investigators t

17、ask can be made easier and more effective if early preservation of evidence is included as part of the accident response preparations. Preserving the accident scene should include securing the area by roping off or barricading it, and limiting access to the investigation team(s). These steps will pr

18、event people from scattering evidence or relocating equipment and materials. They will also help protect people from remaining hazards and prevent activation of equipment or systems that may lead to a second accident.Findings and Observations:1. The contractor does not have a Health and Safety Plan.

19、 According to witnesses, other than training prior to employment with the contractor, they were not aware of written procedures of any formal training program provided by the contractor on the actual operation of shop equipment. General safety training is provided by the contractor, however it is no

20、t combined Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-with specific guidelines on how to operate the equipment safely.2. The saw blade was dull and set too high for the task. The wood blocks the contractor employee was cutting were three-fourths

21、 of an inch thick. Normal practice is to adjust the saw blade so that it clears the top of the stock by about one-eighth to one-fourth inch. Three witnesses stated that the saw blade was set at approximately three inches. A dull blade can reject the material being cut. Contractor personnel interview

22、ed stated that there were sharp blades available.3. The safety guard on the saw was not used. The contractor employee stated he was not able to use the guard due to the size of the wood and the cut he was making. No “push stick“ was used to guide the wood through the blade path. During the tour of t

23、he accident site no push sticks were observed in the shop area. The contractor employee stated that he could not use a push stick because he needed to keep the material against the fence to get a straight cut. This put his hand within three and one-half to four inches of the saw blade.4. In accordan

24、ce with the contractors Safety and Health Plan, they hold periodic safety meetings to discuss general safety issues and employee concerns. The injured employee is the Flight Simulator Support Groups shop safety coordinator. In addition, contractor shop personnel all have extensive first aid and CPR

25、training.5. There is no scheduled maintenance for the table saw. No maintenance records of past service were available. It is unclear whether the saw was ever serviced; these were not determining factors in the cause of the accident.6. The accident occurred on Thursday, January 30, 1992. The Mishap

26、Investigation Board toured the accident site on Friday, January 31, 1992. At that time the accident area had been cleaned and the job setup on the table saw had been dismantled. The accident scene had to be reassembled for the Board to better understand the circumstances of the accident.7. The contr

27、act task for the Flight Simulation Support Group supports mechanical, hydraulic and electronic maintenance, repair, fabrication and modification, simulator cab outfitting, simulator operation and mechanical systems design. Limited wood work also is done in support of the simulators. Quite apparently

28、, however, the work being done by the injured employee was outside the scope of the contract. Witnesses stated that the injured employee was tasked with the majority of the wood work performed by contractor.8. There was a lack of quality first aid supplies in the shop area. When the contractor emplo

29、yees who initially responded to the accident attempted to get gauze or compresses from the shops first aid kit, they did not find anything suitable. Fortunately, another person present had his DART medical emergency kit, which had the supplies needed.9. The ARC Health Unit Doctor or Nurse failed to

30、respond to the injury scene. The presence of a Doctor or Nurse could have provided a calming effect to the situation in addition to professional assistance. However, the individual with DART training who responded provided outstanding support.There were a number of comments made by those on the scen

31、e stating that the ambulance took too long to arrive. Records of the communications between the ARC Duty Office, Security and the Moffett Field Fire Department show that the ambulance was called at 15:20 hours and it arrived at 15:32 hours, which is 12 minutes. In 1991, the overall average time for

32、ambulance response at ARC Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-was 13.8 minutes.Recommendation(s): 1. The contractors Safety and Health Plan should be reviewed and revised to include a training/certification program for individuals on the

33、safe operation of major (table saw, lathe, automatic punch/press, drill press, etc.) shop equipment. Periodic refresher courses should be considered as part of this plan.2. Specific written procedures should be developed for the proper and safe operation of major shop equipment. This should include

34、both basic and critical recommendations.3. A table saw should never be used for cutting small pieces of wood if a push stick cannot be employed or if the stock being cut makes it necessary for the operators hand to be within six inches of the saw blade.4. Insure that safety meetings are held on a re

35、gular monthly basis in accordance with the contractors Health and Safety Plan. These meetings should involve a free flow of safety information between management and the workers. Management should provide support for all reasonable safety requests. This forum should also be used to conduct updates/r

36、eviews of good safety practices of the operation of different major equipment each time.5. All major shop equipment should be on a scheduled preventive maintenance program. The program should not only check for the condition of the equipment, but also evaluate and advise on the condition of the cutt

37、ing tools and other peripheral items associated with the safe operation of the equipment.6. In the future, it is imperative that after a serious accident nothing at the accident scene be altered. Preserving the accident scene will allow the investigators the chance to review and study the actual con

38、ditions and allow photographs to be taken for the record.7. Regular meetings should be held between the Contracting Officer (CO), Contracting Officers Technical Representative (COTR), Sub COTR and contractor to insure that work performed is within the scope of the contract.8. First aid supplies are

39、available through the ARC Stores Stock Catalog. This information needs to be conveyed to the ARC Staff and supplies need to be distributed to the appropriate areas.9. During operating hours, the Ames Health Unit should respond to all 911 emergency calls of a medical nature. Even if their presence is

40、 not needed, it could have a calming/stabilizing effect at the accident scene.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Mission Directorate(s): a71 Exploration Sys

41、temsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Facilitiesa71 Mishap ReportingMishap Report References: ARC Table Saw Mishap Investigation Board Report of March 9, 1992Additional Info: Approval Info: a71 Approval Date: 2002-02-12a71 Approval Name: Anthony Bricenoa71 Approval Organization: ARCa71 Approval Phone Number: 650-604-1012Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-