REG NASA-LLIS-2056-2009 Lessons Learned Building M6-794 Roofing Type A Mishap.pdf

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1、Lessons Learned Entry: 2056Lesson Info:a71 Lesson Number: 2056a71 Submitting Organization: KSCa71 Submitted by: Michael Bella71 POC Name: Dave Facemirea71 POC Email: david.l.facemirenasa.gova71 POC Phone: 321-867-7232Subject: Building M6-794 Roofing Type A Mishap Abstract: On March 17, 2006, a const

2、ruction worker fell from the roof of Supply Warehouse #1 (Building M6-794) at the Kennedy Space Center. Rescue personnel arrived at the mishap scene minutes later, and the worker was subsequently airlifted to the hospital but passed away later that day due to fatal head injuries. At the time of the

3、mishap, the workers were installing a corrugated metal roofing panel as part of Subcontract X04524-6 and the employee was working close to the edge of a roof without proper full protection. Because of this fatality, many recommendations were made to prevent a mishap such as this from occurring again

4、. These recommendations include: requiring physical restraints when working close to edge of a roof, reserving non-physical restraint systems for special circumstances requiring approval through formal variance.Description of Driving Event: On March 17, 2006, a crew of three (two workers and a super

5、intendent) construction workers began to work on the roof of Building M6-794. Before working on the roof, however, the crew needed to wait on an aerial lift that was transporting materials to the roof for panel installations. The three construction workers began replacing the panels on the roof afte

6、r the aerial lift delivered the supplies necessary. They started at the northwest corner of the building to replace roofing at that location and then moved to the southeast corner. As the employees continued to work on the roof, only the Safety Monitoring System was used as fall protection. The Safe

7、ty Monitoring System alone would have been an acceptable form of protection if the width of the roof of Building M6-794 was Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-less than 50 feet; however, this roof had a width of more than 50 feet which c

8、onflicted with OSHA standards. According to OSHA 29 CFR 1926.502(h)(1)(ii), safety monitors are intended to warn the employee when it appears that the employee is unaware of a fall hazard or is acting in an unsafe manner. According to OSHA 29 CFR 1926.501(b)(10), safety monitoring alone is allowed w

9、ithout a Warning Line System on roofs less than 50 ft wide. After the installation of a second panel, the crew took a break for lunch at which point the two employees left the site while the superintendent remained. Upon their return from the break, they resumed work and began installing the last ro

10、ofing panel. While working on the third panel, the superintendent violated the requirements set by OSHA 29 CFR 1926.502(h)(1)(v) as he acted as the superintendent, safety monitor, as well as one who helped replace the third roofing panel. It was while the crew was working on the final when the emplo

11、yee lost his footing, released the panel that was held in his hands, and fell from the roof of the building. He fell approximately 10 feet, struck an air-conditioning unit with his head, and feel and another 7 feet to the loading dock. The worker passed due to severe head injury later that day.Lesso

12、n(s) Learned: The employee was working too close to the edge of a roof (17 Feet above the ground) without proper fall protection. When roofing jobs are preformed, subcontractors are responsible for judging if the standards of 29 CFR 1926.501 (low-sloped roof) and 29 CFR 19.26750 (steel erection) alo

13、ng with the OSHA Standards and letters of Standard Interpretation apply to the work being done. The roofing work should have been classified as a steel erection, for which the Occupational Health and Safety Administration (OSHA) required physical restraints. However, the roofing was misclassified as

14、 roofing done on a low-sloped roof, which did not require any physical restraints. Although OSHA standards allow the use of Warning Lines and Safety Monitory Systems for work done a low-sloped roof, a safety monitor was used only to help the other two workers instead of acting as a safety monitor fo

15、r all three employees, and warning lines were not used. These actions both were violations according to the standards set forth by OSHA. Because of these violations, one of the employees fell from the roof to the loading dock.Recommendation(s): When responding to a Request for Proposal (RFP) and pri

16、or to preparing a safety plan, subcontractors should review OSHA regulations and letters of Standard Interpretation to properly classify the work. Contract Language should include information alerting subcontractors that the OSHA Area Office has a compliance assistance specialist available as a reso

17、urce. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Prior to issuing an RFP, the prime contractor should review OSHA Standards and letters of Standard Interpretations to properly classify work. NASA/KSC and prime contractors should review current o

18、ngoing work involving roofing to ensure proper work classification and compliance with OSHA Standards and letters of Standard Interpretation. Prime contractors should develop a mechanism to ensure that OSHA noncompliances immediately dangerous to life and health are reported to the subcontractor pre

19、sident/top management. Develop a mechanism to ensure that OSHA noncompliances immediately dangerous to life and health are reported to the subcontractor president/top management. - Other prime contractors should develop a similar mechanism to ensure that OSH noncompliances immediately dangerous to l

20、ife and health are reported to the subcontractor president/top management. - For construction contracts that NASA/KSC issues, NASA/KSC should develop a similar mechanism to ensure that OSHA noncompliances immediately dangerous to life and health are reported to the contractor president/top managemen

21、t Prime contractor safety specialists should trend noncompliances and discuss them at the appropriate contractor/subcontractor safety meeting. For construction contracts that NASA/KSC issues, NASA/KSC should trend noncompliances and discuss them at the appropriate contractor safety meeting. NASA/KSC

22、 should develop and implement a fall protection policy and program for low-sloped roofing work that is more stringent than the applicable OSHA standard and requires the use of physical restraints when working within 6 feet of the edge. The use of warning lines and safety monitors or other nonphysica

23、l-restraint systems should be reserved for special circumstances after review and approval through a NASA/KSC formalized variance process. A Center-wide fall protection team (civil servants and contractors) should be formed to examine issues (e.g., standardization across contractors, variance proces

24、sing, retrofitting of existing facilities) arising from the implementation of a new, more stringent fall protection policy and program. Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: Click here to download document. Provided by IHSNot for ResaleNo reproduction or netwo

25、rking permitted without license from IHS-,-,-Mission Directorate(s): N/AAdditional Key Phrase(s): a71 Safety and Mission Assurance.a71 Safety and Mission Assurance.Maintenancea71 Personal Protective Equipmenta71 FacilitiesAdditional Info: a71 Project: N/AApproval Info: a71 Approval Date: 2009-08-05a71 Approval Name: mbella71 Approval Organization: HQProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-