1. Infection and Laceration Bldg 1238B ROME Engineering Project IRIS# S- 2012-159-00005 Prime Contractor Davcon, Inc. June 1, 2012

2. Agenda Background Investigation Proximate and Root Cause Lesson to Share

3. Background An Advex employee was performing NDE testing inside of the.3 Meter Cryo Tunnel. While standing on the work platform the employee knocked an existing scab off his right elbow. The employee was able to contain the bleeding through pressure with a paper towel. The employee then crawled in the tunnel to perform the NDE testing. The open wound got an infection which required hospitalization. The employee was diagnosed with a staph infection. Slide 3

4. Investigation The Advex employee was working on the platform on the upper level of the.3 Meter Cryo wind tunnel. While on the platform the employee bumped his right elbow against the tunnel which dislodged an existing scab. The employee stopped the bleeding with a paper towel and cleaned the wound. He did not report the incident to any of his co-workers. He then crawled into the tunnel to perform his NDE testing. Later, the laceration on his arm became infected which required hospitalization. The infection was diagnosed as a staph infection which required 3 days away from work, making this a Lost Time Injury.

5. Proximate and Root Cause Proximate Cause Treating the wound on his own without covering it prior to entering the tunnel. Root Cause Not seeking proper medical attention to clean and cover the open wound before climbing into the tunnel. Slide 5

6. Lessons to Share ROME has been enforcing the incident reporting policy. Part of this process has been to inform employees that these type incidents could be avoided if proper medical treatment is sought.