Lessons learned from a laser injury event

Abstract

A technician at the Idaho National Laboratory received 2nd degree bums to his left middle and ring fingers while performing maintenance on a Class 4 industrial laser. The task required “target” placement in the beam path to verify mirror alignment. The technician, believing the laser was in a safe mode, reached into the beam pathway to place the target, saw a flash and immediately withdrew his hand. Investigation included a review of lab-wide safety procedures, equipment- specific operating procedures, maintenance documents, and training records, interviews of maintenance technicians, safety support, and management personnel, and a physical verification of equipment condition. Subsequent weaknesses were identified in training, work direction details, the performance of work following vendor-recommended safe work practices, safety professionals’ understanding of a complex system and reliance on the maintenance technician's training and experience to conduct an effective hazard analysis.A technician at the Idaho National Laboratory received 2nd degree bums to his left middle and ring fingers while performing maintenance on a Class 4 industrial laser. The task required “target” placement in the beam path to verify mirror alignment. The technician, believing the laser was in a safe mode, reached into the beam pathway to place the target, saw a flash and immediately withdrew his hand. Investigation included a review of lab-wide safety procedures, equipment- specific operating procedures, maintenance documents, and training records, interviews of maintenance technicians, safety support, and management personnel, and a physical verification of equipment condition. Subsequent weaknesses were identified in training, work direction details, the performance of work following vendor-recommended safe work practices, safety professionals’ understanding of a complex system and reliance on the maintenance technician's training and experience to conduct an effective hazard analysis.