1. Safety Integrity Teamwork Excellence April 7, 2011 Forehead/Eye Laceration at B1244 Annex IRIS # S-2011-098-00001 Classification: OSHA Recordable

2. Safety Integrity Teamwork Excellence Background A NASA Civil Servant employee received a laceration to the forehead and a scratch to the cornea of the left eye. The employee was using a sanding machine in the B1244 Annex when the sanding disk came off and struck them in the face. The employee was given prescription strength medications for the injury, making it OSHA Recordable.

3. Safety Integrity Teamwork Excellence Investigation The employee stated that they were sanding a wooden dowel on a disk sander. On the fourth pass, the sanding disk came off and struck them in the face. On inspection, the sander appeared to be in good working condition, although it was not bolted to the floor as required (Note: floor bolting was not a factor in this incident). Residual adhesive was noted on inspection of the sanding plate (surface to which the sanding disk is affixed). – Failure to clean the surface of old adhesive prior to installation may have caused poor adhesion. – The adhesive may have failed due to age. It could not be determined how long ago the sanding disk was installed.

4. Safety Integrity Teamwork Excellence Investigation Continued The employee reported that they had been trained on use of the disk sander and were familiar with its operation. The employee knew that eye/face protection was required, but decided not to wear it because it was going to be a quick job. The machine was properly labeled Do Not Operate without Eye Protection.

5. Safety Integrity Teamwork Excellence Proximate & Root Causes Root Cause: – The root cause of injury in this case was the failure of the adhesive sanding disk. Proximate causes: – The employee did not thoroughly inspect the machine prior to operation. A pre-use inspection may have identified a problem with the adhesive disk. – The employee made a decision not to wear the required eye/face protection. The use of safety glasses and a face shield may have prevented the injury.

6. Safety Integrity Teamwork Excellence Actions to be Taken The employee should be retrained in the safe use of the disk sander and the proper use of personal protective equipment. The stock of sanding disks in the facility should be checked to ensure that they are not too old. The sanding machine should be mounted to the floor as required before it is operated again. Until that time, it should be administratively tagged do not use.

7. Safety Integrity Teamwork Excellence Lessons to Share Personnel are reminded that they should not become too comfortable around machines. Following the basic safety rules, every time, can and does prevent accidents. – Never operate a machine unless you have been trained in its use. – Always inspect your equipment before beginning work. – Always wear approved eye protection when operating machines. Additional PPE, such as hearing protection and steel toed shoes, may also be needed depending on the machine and job.