Lessons learned from a laser injury event

A technician at the Idaho National Laboratory received 2^nd 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.