In early February 2000, a TSD employee matrixed to the 88-inch Cyclotron, slipped and fell in the machine shop, injuring his left leg. He was discovered sitting on the floor by another employee who phoned the Berkeley Laboratory Fire Department. Paramedics responded and the employee was transported to the hospital for treatment of a broken femur.

Upon investigation, several factors were found to contribute to the accident:

1. The fatigue mat that the employee slid on was very old. Oily material had actually absorbed into the mat.
2. The floor of the machine shop was slippery due to a build up of cutting oils. This allowed the mat to slide on the floor causing the employee to slip.
3. In the past, the Facilities Department periodically cleaned the shop floors with a tri-sodium phosphate solution to remove the oily deposits. At some point, the performance of this service had been changed to a request only basis. Machine Shop Supervisors were unaware that they could request this service. Consequently, normal maintenance of the shop floors consisted of spreading an absorbing material (dry sweep) on spills followed by sweeping. This was not always sufficient in eliminating the slip and fall hazards resulting from oil build up.

1. All fatigue mats in the 88" Cyclotron Machine Shop have been inspected to ensure that the mats have not degraded and that oil had not collected underneath.
2. The shop floor was cleaned with the tri-sodium phosphate solution following a Work Request to Facilities. This improved the footing in the shop significantly.
3. Routine inspections of the floor are currently being conducted. Shop supervisors and employees have been instructed to call the Work Request Center (Extension 6274) to have Facilities clean the floor, as needed.
4. The TSD Safety Coordinator has begun inspections of all machine shops to which their employees are matrixed. These are being conducted in conjunction with the Safety Coordinators from those matrixed divisions. This collaborative effort is to ensure the safety of all machine shop employees.
5. Supervisors of other LBNL machine shops will be advised of this accident and subsequent corrective actions via the LBNL Lessons Learned Program.

Any questions regarding this event may be directed to Curtis Nunnally at Extension 5966.