1. Safety Integrity Teamwork Excellence December 14, 2011 Sprain-Left Shoulder IRIS # :S- 2011-349-00002 Classification: OSHA Recordable

2. Safety Integrity Teamwork Excellence Background An employee received a partial dislocation of their left shoulder when they slipped and fell in a restroom stall. The employee sought treatment at the NASA Clinic and was given a prescription strength medication for pain, making this an OSHA recordable injury. The employee was referred to an orthopedic specialist for follow-up.

3. Safety Integrity Teamwork Excellence Investigation When the employee flushed the toilet, he noticed a leak at the handle of the flushing mechanism. The leak wet the floor at the base of the toilet. As the employee attempted to turn around and exit the stall, he slipped. He attempted to break his fall by grabbing onto the door frame, injuring his left shoulder. The employee did not notice any water on the floor upon entering the stall. Finger caught in opening left by missing lock-side filler. The restroom was well lit. However, it was noted that the light from the window was shadowed by the stall doors, and the backs of the stalls were noticeably more dim. The restroom floor was in good condition and no imperfections were noted.

4. Safety Integrity Teamwork Excellence Investigation After the accident, the restroom stall was taped off and the leak was reported to ROME for repair. Maintenance records indicate that the repairs to the flush mechanism were completed within two days. Further review of maintenance records showed that no leaks had been reported prior to this accident.

5. Safety Integrity Teamwork Excellence Actions Taken The restroom stall was taped off immediately and the leak was reported to ROME for repair. Repairs to the flush mechanism were completed within two days.

6. Safety Integrity Teamwork Excellence Root Cause Root Cause: – The root cause in this case appears to be the breakdown of the flushing mechanism on the toilet which caused it to leak when it was activated. There was no indication that this was a known leak that had not been addressed. Proximate Causes: – The floor in this restroom has large tiles with few grout lines. Water tends to pool and make the tiles slippery. – The light in back of the stall is dimmer than other areas of the restroom. The stall door creates a shadow effect on light coming in from the window. This could have made it more difficult to see the water from the leak.

7. Safety Integrity Teamwork Excellence Lessons to Share This accident underscores the importance of reporting water leaks and securing the area as soon as they are noticed. Employees are reminded to be extremely careful if they encounter water on a floor.