1. Safety Integrity Teamwork Excellence August 13, 2013 Wrist Injury in Building 648 IRIS # : S-2013-225-00002 Classification: Restricted

2. Safety Integrity Teamwork Excellence Background On August 13, 2013, at approximately 8:40a.m., an employee was walking on the oily metal floor surface inside the Transonic Dynamic Wind Tunnel (TDT) in building 648 to complete a blade inspection, at which time the employee slipped on the floor surface and landed on the left wrist and buttocks. The employee immediately felt pain in the left wrist, and sought medical attention at the NASA LaRC clinic. The employee was then referred to a specialist offsite for further evaluation and treatment. The employee was diagnosed with a broken wrist. This injury has been classified as an OSHA Recordable with Restricted Duty and NO Lost Time.

3. Safety Integrity Teamwork Excellence Investigation This particular area of the tunnel is hard to reach, so access is restricted to authorized personnel only. The area around the blades is accessed infrequently. Due to the construction of the tunnel and the nature of the operation, there is a constant film of oil on the entire inner-tunnel surface. Everyone who enters the tunnel is made aware of this and it is in facility safety heads annual safety briefing slides. Additionally, slip resistant safety shoes are required to be worn while inside the tunnel (the employee was wearing regular tennis shoes). There is no floor grating or handrails in the location of the incident. Due to the large surface area, it is not feasible to clean the oil prior to inspection.

4. Safety Integrity Teamwork Excellence Proximate & Root Causes Root Cause The requirement for slip resistant shoes was informal and often ignored by employees. Proximate Causes The employee was wearing tennis shoes while walking across the oily tunnel floor surface. Policy for wearing slip resistant shoes while in the tunnel was not strictly enforced or adhered to. The lack of engineering controls and other work practice controls may have been contributing factors.

5. Safety Integrity Teamwork Excellence Actions Taken As a corrective action, the FSH sent an email to facility personnel and posted several signs around the facility indicating areas where slip resistant safety shoes must be worn. The requirement for slip resistant safety shoes to be worn has always been an informal policy and was mostly ignored. A job hazard analysis has been completed and this requirement has now been formalized by procedure. The FSH briefed all tunnel operators about this incident and the requirement for slip resistant footwear at the September safety briefing.

6. Safety Integrity Teamwork Excellence Lessons to Share Failure to formalize and enforce safety policies can lead to accidents. This accident may have been prevented by strict adherence to the informal policy requiring slip resistant shoes while working in the tunnel. Slip resistant shoes should be worn whenever working on oily floor surfaces. They minimize the risk of a slip, but do not eliminate the risk completely. Eliminating oily residues and/or providing engineering controls is preferred when possible. The installation of floor grating and handrails may be a long term engineering control if feasible and if permitted by the configuration of the tunnel around the blades. Employees must be aware of their center of balance when walking on slippery surfaces, and adjust their gait and pace accordingly.