1. Safety Integrity Teamwork Excellence March 5, 2012 Shoulder/head injury in B 1228 S- 2012-066-00008 Classification: OSHA Recordable- Restricted

2. Safety Integrity Teamwork Excellence Background An employee injured their shoulder and head when they fell out of an office chair. The employee was leaning back when the chair suddenly tipped backwards. The injury was classified as OSHA recordable with restrictions. These restrictions were accommodated by the employer.

3. Safety Integrity Teamwork Excellence Investigation The employee leaned back in a wheeled 5-legged chair as they had done many times in the past. This time, the chair suddenly tipped backwards causing the employee to fall out and strike the wall behind them. The chair was designed to lean back. The chair was in a common area shared by many people. No one had noticed or reported any problems with this chair before. Finger caught in opening left by missing lock-side filler.

4. Safety Integrity Teamwork Excellence Investigation The chair had an adjustable tensioning device. The employees supervisor indicated that it seemed as if the tensioning spring had failed, but this could not be confirmed. The chair was disposed of immediately and had been replaced by the time of the investigation. Finger caught in opening left by missing lock-side filler.

5. Safety Integrity Teamwork Excellence Proximate & Root Causes Root Cause. The root cause of this accident appears to be the failure of the tensioning device in the chair. However, improper adjustment of the tensioning device could not be ruled out.

6. Safety Integrity Teamwork Excellence Actions Taken The chair was disposed of and replaced.

7. Safety Integrity Teamwork Excellence Lessons to Share It is important for employees to be aware of the potential for chairs to degrade over time and remove them from service when they appear to be no longer safe to use.