What happened: At Los Alamos National Laboratory (LANL), a rigging crew moving an electrical transformer had to change their plan on the fly after finding the building elevators out of service. A misunderstanding during the pre-job brief led the crew to manually lift and slide the heavy transformer between pallets, causing it to slip and crush a worker’s middle finger, which resulted in a partial amputation.
Why it matters: Modifying an approved work plan in the field without formal reassessment introduces unexpected hazards and severe pinch points. Rushing into informal workarounds or relying on assumptions instead of clear, verified communication can turn a routine equipment move into a life-altering injury.
Your action: The 3-step change control rule:
- Pause when the plan breaks: If broken equipment, missing tools, or changing field conditions prevent you from following the approved work package, pause the work immediately.
- Reassess hazards before restarting: Do not improvise manual lifting or rigging workarounds without formally reviewing the new hazards, pinch points, and required equipment with your safety team.
- Use three-way communication: Ensure every crew member and supervisor has an identical understanding of the revised steps before touching the load. Never guess what someone meant during a briefing.
Discussion question: “If our primary equipment fails or isn’t available today, do we have a clear trigger to pause and re-plan, or do we try to force the job through with informal workarounds?”
