Time Pressure and a Lack of Hazard Recognition Contribute to Broken Overhead Light Tube
825 Views
Feedback
0 Comments

Favorite
Image for Time Pressure and a Lack of Hazard Recognition Contribute to Broken Overhead Light Tube

Type:  Lessons Learned

Publisher:  Pacific Northwest National Laboratory (Richland WA), Richland, WA (PNNL)

Published As:  Public

Date: 

Topics:  Startup Readiness, Laboratory, Hazardous Energy Control

A Project Manager (PM) was performing troubleshooting on a prototype pressurized (pneumatic) system. The system utilizes pressurized air to move a small, lightweight plastic capsule through the system. While attempting to determine why the system was not operating as designed, a coupling came loose and shot the capsule into the overhead fluorescent light, breaking the diffuser and light tube (pictured). A small amount of broken glass landed on the benchtop below, but the PM was not injured.

The PM had been in a hurry while troubleshooting as he had a flight to catch. He wanted the system to be operational before he left so it could be used by other staff who would continue to test the system in his absence.

In this Lessons Learned article, you'll read about how time pressure, a lack of hazard recognition and established controls, and communication challenges combined with a system that was not yet fully operational to lead to this event.

You must be logged in to open the attachment.

Download Article
Comments about this Article
You must be logged in to add or view comments.
Related Articles
Feedback Form
How did you apply this information?
You must be logged in to use this feature
Is this article applicable to your organization?