James Joyce said, "Mistakes are the portals of discovery." Similarly, SLAC takes the opportunity to learn from unfortunate incidents so we can prevent them in the future. We call this the ‘lessons learned process.’ This article explores the lessons to be learned from a recent accident at SLAC.

In January, an employee fell from a ladder and sustained a head injury. Fortunately, the employee has since returned to the workplace. On the day the accident occurred, SLAC began an investigation with the goal of better protecting employee safety. More severe accidents are investigated by the Department of Energy (DOE) and this accident met the DOE’s criteria for additional review. DOE began their investigation a few days later.

Aaron Gooch (ESH) demonstrates the proper use of a ladder (Photo courtesy of ES&H)

Unfortunately, similar issues continue to be observed. During a recent DOE walk-through, ladder use and fall protection issues were brought to our attention. We quickly resolved the issues. As a result of the accident and of these incidents, SLAC and DOE should and will look harder to ensure that the workplace is safe. It is the welfare of staff and users that motivates these activities.

We have all used ladders—but don’t let this familiarity breed complacency. The American Academy of Orthopedic Surgeons recently published statistics that illustrate the dangers of ladder accidents. In the U.S., more than 500,000 people a year are treated for ladder-related injuries, and that number does not include people who suffered injuries but did not go to a medical care provider for treatment. About 300 people in the U.S. die from ladder related injuries annually.

Safety Enhancements

The SLAC and DOE investigations recommended the following enhancements to SLAC safety systems.

First, to encourage improved safety accountability, safety must be included when preparing goals for SLAC at all levels, from divisions to employees. Moreover, SLAC staff must be held accountable to these goals within the performance evaluation process. In that way, all SLAC goals are identified, responsibility for implementation is assigned and compliance is verified.

Second, when approaching work, all employees and supervisors should go through the process of scoping the work, identifying the hazards associated with that work as well as the cause of the hazards, identifying the controls associated with each hazard and then performing the work using appropriate controls. Then, while performing the work, think about what you are doing, not what you are going to do.

Third, employees and supervisors of employees who use ladders should remind themselves of proper ladder use by reading ES&H Manual chapter 15, ‘Ladders, Scaffolds, and Work Platforms’ and by taking the ES&H training course ‘Stairway and Ladder Safety’. The ES&H Manual chapter and the course will remind you of your responsibilities when using a ladder and will refresh your understanding of ladder safety information.

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