Ladder Safety Lesson Learned

January 18, 2006

A JLab Facilities Management employee fell about six feet while descending an ARC Building vertical ladder on January 11. He broke his right arm as a result of the fall. There were no conditions noted to cause the ladder rungs to be slippery. According to the employee, he lost his grip and could not recover in time. The ladder in question, about 14 feet in height, is the sole means of access to a rooftop mechanical equipment enclosure that provides HVAC and domestic hot water for the ARC Building. Routine and corrective maintenance necessitate access to the roof at least once per day on average.

Facilities Management suspended elevated work until all workers and subcontractors were briefed on this event and elevated work safe conduct. An injury investigation is in progress to determine what corrective actions are needed to prevent future injuries on this fixed vertical ladder or other similar ladders at JLab.

All of us at JLab should evaluate our everyday tasks for injury potential and the need for safe work practices. While most of us may not climb ladders daily, we can all use the five steps of /SAFER/:

  • Summarize critical steps - What are the critical phases of the task? What parts of the task must absolutely go right?
  • Anticipate errors - How could we make a mistake at each point? Are there time pressures, unclear roles & responsibilities, imprecise communications, interruptions, personality conflicts, stresses, assumptions, or complacency?
  • Foresee consequences - What is the worst thing that can go wrong if a mistake is made at each point?
  • Evaluate defenses - What can we do to prevent the mistake? Assure sufficient schedule, have workers repeat back instructions, keep track of stop/start points, promote questioning attitudes, and have others monitor activities.
  • Review operating experience - How has this been done in the past? What mistakes were made? How can we avoid them?


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