1. Safety Integrity Teamwork Excellence June 21, 2013 Shoulder Sprain in Building 1148 IRIS # : S-2013-189-00004 Classification: Restricted

2. Safety Integrity Teamwork Excellence Background An employee was climbing a fixed ladder (located between the mezzanine and attic in room 104 of building 1148) with only one hand free and the other hand carrying a tool, at which time the employee slipped partially off the ladder but did not fall. The employee began to feel pain in the right shoulder area and sought medical attention 10 days following the incident at the NASA LaRC clinic. The employee was then referred to an orthopedic specialist. The employee was diagnosed with a sprain/strain to the right shoulder and sought physical therapy to aid in the healing process. This injury has been classified as an OSHA Recordable with Restricted Duty and NO Lost Time.

3. Safety Integrity Teamwork Excellence Investigation The purpose of climbing the ladder was to access the attic in order to survey equipment using a Trimble Nomad PDA handheld scanning device. The employee proceeded to climb the ladder with the right hand free and the left hand carrying the handheld scanning device. Since the employee could not actually grip the rungs with the hand that was carrying the device, the left forearm was used instead by placing the forearm around the left, vertical, ladder support rail (see photo on right-slide #5) as the employee climbed the ladder. About halfway up the ladder, the employees left arm slipped, causing the employee to lose balance. While only holding on to the ladder with the right hand, the employees body dropped several inches and swung away and to the right of the ladder in a counter-clockwise direction. Upon regaining balance on the ladder, the employee continued on with the task.

4. Safety Integrity Teamwork Excellence Investigation Supervisor notified of injury 10 days after the incident. Supervisor immediately ordered a stand down of the project upon notification of injury. The supervisor brought in organizational safety professionals to discuss ladder safety and proper climbing techniques. During the stand down other team members shared techniques employed in the field on this project to include: (The buddy system, the rope system, sliding the nomads onto their forearm using the loops on the back of the device and placing the device in their pockets.) At the request of female project members, the supervisor ensured the availability of backpacks to carry the device.

5. Safety Integrity Teamwork Excellence Investigation Note: This is a similar size scanning device that the employee was holding in the left hand while climbing the ladder. Note: Position of left arm while climbing ladder. Note: (employees forearm was around the rungs while climbing)

6. Safety Integrity Teamwork Excellence Proximate & Root Causes Root Cause – Failure to follow proper procedure Proximate Causes: Improper climbing technique Only one hand was free while climbing ladder Employee did not use hands-free method for carrying the scanner. (i.e. backpack/holster)

7. Safety Integrity Teamwork Excellence Lessons to Share (from this and similar incidents) Both hands must be free when climbing fixed ladders. Carry tools in a back pack or utility belt. Management was proactive in discussing with personnel the safety in working with handheld objects prior to task.