Lessons Learned from a Laser Injury Event - Limitations of Skill-Of-The-Craft
A technician at INL received 2nd degree burns to the middle and ring fingers of his left hand while performing a preventive maintenance (PM) procedure on a Class 4 industrial laser on August 30, 2011. The task required placement of a “target” 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. Three INL technicians were assigned to perform a 2000 hour run time PM on a laser. A pre-job briefing was held August 29, 2011 by the acting foreman and the technicians started the PM. They had completed 25 steps in Section I of the work order by the end of the day. The laser systems were placed under LO/TO and the internal optics were cleaned and/or replaced. The LO/TO was released and the next morning, August 30, 2011, the technicians prepared to take a diagnostic shot inside the internal optics. The laser was powered up at the HMI, and the person in charge (PIC) selected the “Mirror Alignment” program from the human machine interface (HMI) screen, enabled the pendent and pressed the “Cycle Start” button. The technicians believed the laser was in “simmer” mode at this point and that no beam was being generated out of the resonator. A beam was being generated in the “Mirror Alignment” program when the “Cycle Start” button was pressed. They decided to check the #4 aperture target and see if they were aligned at that location. One of the technicians reach to place the target at the end of the Z box and a “Flash” occurred. The technician immediately retracted his hand with the target. The PIC turned off the high voltage (HV) at the pendent. The foreman and supervisor were informed of the incident and the injured technician was escorted to an onsite medical facility. The nurse evaluated the injury and sent the technician to a physician for further evaluation. A physician examined the technician’s hand. The technician’s left middle and ring fingers received 2nd degree burns to both finger tips. A prescription burn ointment and bandage was applied. The employee was returned to work with no restrictions.