An employee’s left foot was bruised during an operation to unwrap a 15-foot, 70-pound rod. The rod, which is used to transport magnets, unexpectedly rolled off a 36-inch-high work cart and struck their leather steel-toed safety boot.

The incident occurred as the team adapted to a new packaging method. Historically, these rods were received in crates and packaged unwrapped, allowing employees to follow an established process for safe handling. When the switch to taped protective wrapping was made, the team quickly adapted, using standard techniques to carefully slice the tape with a box cutter while avoiding scratches on the rods.

Despite their care and attention to quality, the rod rolled off the cart, causing the injury. Following the incident, ATAP and Engineering Division Safety Coordinators collaborated with the team to analyze the event, ensuring it became a shareable learning opportunity. Together, they examined the process to understand better how to handle changes in packaging for these rods, avoid such incidents, and minimize risks in the future.

Through their collaborative efforts, a key recommendation was to discuss such routine tasks at regular team meetings to identify changes ahead of time and determine a path forward. The team also proposed several improvements to operations:

• An alternative method of securely transporting the 15-foot rods within the facility involves stabilizing them during inspections with wood blocks.
• Minor scratches from a box cutter while cutting tape don’t impact the rod’s quality or performance, giving the team more flexibility in removing the protective wrapping.

Proactively discussing routine tasks and identifying solutions/improvements before a task is performed are essential for team communications and effective work planning. Learning from these incidents helps us understand and manage our safety risks.

For more information on ATAP News articles, contact caw@lbl.gov.