June 18, 2012

Fall From Ladder- B1250

IRIS# S- 2012-171-00002

OSHA Recordable With Lost Time Days

Background

• The employee was tasked to replace ceiling tiles in bldg 1250. The employee had been working from an 8-foot ladder to access the area. During one of the trips down the ladder he did not realize that he was on the third rung and stepped back thinking his foot would land on the floor. Because the employee was two rungs higher than he thought, he lost his balance and fell backwards striking his tailbone.

• The employee was treated initially at the onsite NASA clinic and then transferred to Sentera Careplex.

Slide 2

Investigation

• The employee’s role in the task changed as he went from aground person to actively going up and down the ladder.

• The employee indicated that he does not work from heights.

• The appropriate resources were available and used. Other options had been discussed such as a lift or a rolling scaffold.

• The employees working the task felt most comfortable working from the ladder.

Root Cause

Root Cause

• Because the employee typically does not work from heights he was out of his comfort zone.

• The employee lost track of his destination on the ladder and stepped back thinking his foot would land on the ground. When the employee’s foot did not land as he thought it should have, the employee lost balance and fell backwards.

Slide 4