Publications Details
Slip Causes Fractured Ankle 905/1201 (Causal Analysis Report)
The problem statement from which the Causal Analysis Team focused was, "A Member of the Workforce (MOW) from Department 8862 sustained a fractured ankle while traversing a 7.5- inch-high elevated aluminum cover over conduits located in NM Building 905, laboratory 1201 that houses a gas gun." The analysis revealed the following causes that directly contributed to this event: Root Causes: 1. The landing area from the downslope on the flammable cabinet side of the aluminum conduit cover was not sufficient; and 2. The surface of the aluminum conduit cover was too smooth.