April 27, 2009

Introduction Nails_GNU agreement.jpg


Nail guns are an extremely common tool used in many aspects of construction, particularly in residential applications. [1] They can have a number of different configurations and drive a number of various sizes or types of fasteners into wood or concrete. [1, 2] They were developed in 1959 to increase productivity, as an average house will require 50,000-70,000 nails during its construction. [1, 3] Specifically, pneumatic powered guns for wood framing, interior carpentry, sheathing, and roofing are utilized the most often, and can easily drive a 3 to 3.5 inch nail into wood in less than a tenth of a second. [1, 4] They are common, both on the job and at home, available for public use, easy to acquire, and easy to use. However, the use of a nail gun should not be considered an unskilled task, and the danger of nail guns should not be underestimated. Misuse or malfunction of nail guns can cause serious injury and harm, to the user, fellow co-workers, or by-standers.

Magnitude of the Problem and Nail Gun Trends

Several major studies have examined nail gun injuries in construction workers. When examining construction data for nail gun injuries, researchers usually looked more specifically at the following groups and activities because of substantial nail gun use and increased exposure compared to general construction:
• Residential construction
• Carpenters
• Drywallers
• Framing
• Rough carpentry
• Roofing activities

In Dement et al., [1] 66% of nail gun injuries were concentrated in the framing and sheathing stage of operation, followed by roofing, and then exterior siding and finish carpentry work. These findings were also mirrored by other research, and coincide to observable aspects on the jobsite such as: [4, 5]
• Framing nailers are typically larger and more powerful
• Nailing done in this stage of construction requires awkward positions
• Work at heights
• Handling and balancing loads is common
• Jobsite is less organized than later in the building process
• Nailing of roof and floor sheathing is usually done with bounce nailing

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Employees are Commonly Exposed to Heights and Numerous other Hazards During the Framing Process

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Poor Housekeeping During the Framing Stage of a Residential Jobsite

Baggs et al., [5] did an initial study in Washington state on nail gun injuries and rates using workers’ compensation claims:
• 79.8% of all the nail gun injuries reported (3616) resulted in medical-only claims
• Approximately 20% of claims resulted in indemnity payments

Dement et al., [1] conducted a study based on Ohio and North Carolina residential construction workers to determine their rates of nail gun injury. The study found the following rates and results:
• NC carpenters had a 0.91 per 200,000 hour nail gun injury rate
• OH carpenters had a 1.32 per 200,000 hour nail gun injury rate
• 2.06 cases per 200,000 hours for wood framers overall
• 0.66 cases per 200,000 hours for interior carpenters overall
• Lost time cases in NC made up 25.5% of claims,
• Lost time cases in OH were 8.3% of claims
• In OH, workers ages 20-24 years had a higher rate of injury, 0.69 per 200,000 hours
• 4% of injuries were due to nail guns out of all claims in the overall population
• Punctures accounted for 80-89% of all nail gun injuries in the study population

Lipscomb et al.,[4] did a large scale, active surveillance study involving union residential carpenters and drywallers. The study included 5137 carpenters who worked with one of 20 contractors (St. Louis, Missouri area), and accrued over 9,346,603 hours during the course of the study. Two experienced, trained, union journeymen carpenters actively surveyed the study population about nail gun injuries, capturing detailed information on the nature and circumstances surrounding the nail gun incident. Many more injuries were captured due to the active surveillance method than by the use of injury log or workers’ compensation claim reporting. This study yielded very important information on nail gun injuries:
• Of all the injuries reported, 14% were due to nail gun injuries.
• Over 20% of the struck-by injuries on the jobsite were from nail guns
• The majority of injuries penetrated hands or fingers
• Apprentices had a 3.7 per 200,000 hour rate of injury
• Journeymen (more experienced and older) had a 1.2 per 200,000 hour rate of injury

In a later study by Lipscomb et al., [6], focusing on just on apprentices, results showed some important nail gun trends specific to this younger and less experienced group of workers.
• 25% of apprentices reported a nail gun injury within a year of the study
• 12% of injuries were caused by another using the gun and injuring the apprentice
• Overall injury rate for these apprentices was 10.3 per 200,000 hours
• This rate (10.3) was almost three times as high as calculated in previous study (3.7)

An overall trend among all the studies was that hands and fingers accounted for the majority (up to 66% reported in studies) of nail gun injuries[1-3, 6-8]; but, incidences of paralyzing spinal cord injuries, organ perforations, eye injuries causing blindness, fractures, brain damage, severe heart and lung injuries, and even death have been reported. [1, 3, 4, 6-9] After hands, the most frequent sites of injuries were the foot, knee, toe, eye, thigh, and wrist. [1, 5] Nail guns are a definite source of jobsite injuries, and especially are a major contributor to struck-by injuries on the jobsite.

Nails fired from a nail gun can have the penetrating characteristics and abilities of bullets, and are very similar to low velocity gun shot wounds. [9, 10] They also have the projectile free-flight speeds of over 200 mph. [3] Attention to safety and proper work practices is very important, and the primary safety mechanism on a pneumatic nail gun is the trigger mechanism working in combination with the contact element in the nose of the gun to prevent accidental discharge of a nail. [6] The above studies also show that the majority of these puncture injuries were caused by bypassed and/or inoperable safety mechanisms on the guns. [1]

Risk Factors for Injury

Certain jobsite situations or work practices increase the exposure to injury for anyone using a nail gun. Overhead positions, working at heights, awkward postures, and nailing tasks that involved through-nailing (nailing two pieces of wood together) with beams, studs, blocks, and trusses, along with toe nailing (nailing at an angle through two or more members) [4] are all situations that increase the risk of nail gun injuries. [1] In addition, most nail guns are connected to a compressed air supply by a long hose, which is a tripping hazard as workers move and climb around the site.

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Overhead Position

Working at Heights While Setting Trusses- A Nail Gun Incident Can Also Cause Falls

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Awkward Postures

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Work at Heights and Awkward Postures

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Work at Heights and Awkward Postures

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Toe Nailing

Work practices, such as body positioning that allows the gun to be fired toward the worker or moving around the site with a finger on the trigger also increases risk of injury. [1]

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Incorrect Hand and Body Positioning-Poor Work Practice

Injuries often occur to the non-dominant hand (91%), as it is used to position and grip materials and often comes in the line of fire from the nail gun. [8, 10] The most common causes of nail gun injuries include [1, 6, 9, 11]:

• Accidental firing of the gun and double fire;
• Careless handling of equipment;
• Over penetration of the projectile through the material;
• Ricochet;
• Shattering of projectiles;
• Structural unsoundness of material;
• Defective equipment.

The largest single factor that increases the risk of nail gun injury is the use of the contact trigger and locking the gun into fire mode. There are two types of triggers that are used on nail guns. The most common is the contact trigger. This type will allow a nail to be fired anytime the nose element and trigger are depressed simultaneously, and it does not matter which is depressed first. The nose may be depressed on accident when an employee bumps the nose against himself or another person, especially when climbing up or down. Double fire can occur when the energy and recoil of the gun lifts the nosepiece after firing, and the downward directed force of the employee pushes the nose back down and makes contact, re-firing the gun unexpectedly. [1, 4, 6]

An especially dangerous technique used with this trigger is called “bounce” nailing, [3] in which the trigger is locked into the firing position and the gun fires whenever the nose is depressed. Most guns have a device that easily locks the trigger with a simple adjustment to over-ride the safety mechanism, but if it does not, it can easily be improvised on the jobsite.

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Safety Mechanism- Deactivated with a Simple Rotation Adjustment

This is perceived to increase production, and employees can fire off many nails very quickly. The majority of puncture injuries are due to accidental misfire or double fire that involve an employee using a gun with a contact trigger. Using a contact trigger creates twice the risk for nail gun injury to employees. [1, 4, 6]

The other design of trigger on nail guns is called the sequential trigger. The two types of triggers look exactly alike, and you cannot tell the difference between them except by the way the gun fires. The nose element on the sequential trigger must be depressed first, then the trigger second, for the nail to fire. The sequential trigger will require the user to completely release the trigger and lift the nosepiece from the surface before re-firing. The trigger cannot be locked into fire mode and it will not accidentally discharge if the nose bumps a surface or worker. [4] They also prevent against double fires. [11] Most injuries, especially those due to accidental misfire can be prevented, in large part, by the use of a sequential trigger. Lispcomb et al., [4] showed that sequential triggers would have prevented 65% of injuries from tools with contact triggers. Overall, the use of sequential triggers cuts the risk of injury in half, as compared to a contact trigger, even after adjusting for training and experience [1, 4, 6].

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Contact and Sequential Triggers Look the Same From Simple Observation

In addition to the use of a sequential trigger, training is also very important and lack of training is a major risk factor. Young and less experienced employees and apprentices are consistently more likely to receive a nail gun injury. These young and less experience employees have three times the injury rates of older employees and journeyman. [4]

Potential Outcome of Injuries

Nail gun injuries are highly underreported and under treated. [6, 7] Nails are very sharp, and entrance wounds are small, [9] so employees will often pull out the nail and continue working, usually only seeking treatment if the injury is deep or they cannot remove the nail. [6, 8] But, reporting the injury, thoroughly cleaning the wound, and seeking medical treatment are very important because of the functional aspects of the nails.

Nail strips are often glued or adhered together with a resin, plastic, or adhesive coating into long strips that feed into the barrel of the gun.

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Nails are Adhered Together and Joined With a Paper Coated Strip

When the gun is fired into the wood, the friction heats the glue and melts it. When the nail enters wood, the glue will quickly harden and fuse the nail to provide extra durability. This poses a problem when a nail enters the body, because the melted adhesive will also enter the wound, cool, harden, and fuse. [2, 3, 10] Soft tissues will stick to the coatings, the coatings are not easily removed from the wound, and they are clear and hard to identify. [7, 9]

The body will react to the foreign body and this can cause swelling and infection. [9] Medical exploration of the wound is often necessary to ensure complete removal of all coatings or adhesives. [2, 3, 9] Additionally, very small pieces of clothing or surface skin can be dragged into the wound upon the nail entrance, and these also aid in the production of infection. [3, 7] Infection is very common if the nail has penetrated a joint. [12]

Another functional aspect of the nail can also complicate nail gun injuries. Barbs, to improve the grip of the nails in the wood, will hold onto surrounding tissues and vital structures. If the nail is removed incorrectly, more damage can be caused. [1, 2, 10]

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X-Ray of Nail Through Hand
Picture Obtained From: I Have a Nail “Stuck” In My Hand [2]

Focusing on just the hand, the most common site of injury, when a nail penetration occurs, any number of tendons, ligaments, vascular structures, or nerves in the hand can suffer a direct hit from a nail gun injury, or they can be pinched or occluded by the nearby nail. [9]

Economic Costs

Employees have an extremely low perception of the significance of nail gun injuries, and they are not regarded as serious. In reality, they can cause permanent damage to tissues, nerves, and tendons, resulting in loss on function, which has very costly consequences for carpenters and those that earn a living with their hands. [2, 3] Hand injuries are a significant cause of lost work, disability and decreased productivity both on the job and in the home. [3, 4, 8, 9]

Although much focus is on occupational nail gun injury, large increases in nail gun injuries from home use have also occurred. Injuries at home have major economic costs because of their effect on work productivity, along with medical care costs and time off of work, which is largely paid for by the employer. [13]

In Baggs et al., [5] study of the Washington state workers’ compensation data, an average total cost of $692,548 per year was spent on nail gun injuries over the course of the nine year study period, worth an average cost of $1,723 per claim. They found that claimants in the wood framing sector classification, which accounted for the highest percent of nail gun injuries, also account for 60% of the lost time claims reported. Only 20% of claims resulted in more than three days away from work, but in those claims that resulted in lost time, injured employees spent an average of 60 days away from the job.

In the North Carolina and Ohio study mentioned previously, workers’ compensation rates varied widely. In North Carolina, the mean medical cost for claims was $1,497, and mean indemnity was $772. However, the high end of the claim range was $43,805 for medical and $104,191 for indemnity. In Ohio, mean non-lost time claim cost was $483, and the mean cost for indemnity claims was $9,237. [1] In Lipscomb’s 2003 study, [4] over half the men with nail gun injuries lost work time, and one injury required a very lengthy hospital stay.

To most effectively treat a nail gun injury, patients should be referred to a hand specialist for both the removal and subsequent treatment of the injury. [2] The final outcome will have better results, but costs due to specialist involvement are increased.

Barriers to Improvement

Due to the nature of construction work, particularly residential construction, it is hard to quantify precise exposure, yet residential employees are the workers using and being exposed to nail guns the most. [11] Small crews work on many sites; they do many different tasks, and have many different levels of nail gun use. The challenge in quantifying exposure leads to difficulty in determining risk estimates. [6] There is also a growing realization that injuries in construction, especially residential construction, are greatly underreported and underestimated. [6]

Jobsite norms and peer pressure often cause employees to not seek medical treatment for nail gun injuries. If employees do seek care, there is often a poor follow-up rate for care, treatment, and therapy after a patient has initially made a doctor’s visit. This puts a special importance on providers being detail-oriented, thorough, aggressive in treatment and infection prevention, and very clear on wound care and education about the injury, because they most likely will not see the patient again. [3]

In most construction operations, employees are responsible for furnishing their own hand tools, while the company owners will provide all the power tools that are needed. This is the normal practice; thus, many employees do not have a choice in their power tools or the trigger design that is available on the jobsite. This leaves the vast majority of responsibility up to managers and employers and they have to make the effort to protect employees by purchasing guns with sequential triggers, and replacing or retrofitting guns with contact triggers. [4]

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An Employee Uses an Older Model Company-Owned Nail Gun With Contact Trigger

The sequential trigger is a proven, engineering method to remove a hazard from the workplace and reduce injuries; yet it is still not the industry standard or widely used, [4] nor is it required by any OSHA regulation. As far back as 1987, recommendations have been made to move to a trigger mechanism that did not allow rapid firing, [4] and a patent for sequential triggers has been in place for almost 30 years. [6] Beginning in May of 2003, the International Staple and Nail Tool Association (ISANTA) began calling for shipping sequential triggers on framing nailers and more safety labeling as part of a voluntary ANSI standard. However, contact triggers are still shipped in the same box and the user can easily, and often does, switch back to the contact trigger. [6, 11] Also, as mentioned above, contact and sequential triggers look exactly the same, and you cannot tell the difference by looking at them. The sequential triggers are becoming more known and accepted and making their way onto sites, but Lipscomb’s study [6] reports that 2/3 of the nail guns on sites still have contact trip triggers. Nail guns are an investment and often will stay around on the jobsite for many years, and sequential triggers can easily be switched out, so the effectiveness of only a voluntary standard appears to be low, considering the prevalence of contact triggers still being reported.

In addition to using a sequential trigger, a complete and effective training program is also required to further reduce injury and protect employees, especially those that are young and inexperienced. [6] Complete training programs are not the norm, and it is very likely that the safety and handling instructions may not be included or present with tools. If instructions are included, there is no guarantee that the user will read them, understand them, or follow them. [2] Printed instructions in English pose a special problem for those who cannot read or who cannot read English. Also, as the residential workforce becomes made of more immigrants and non-English speakers, training on proper use becomes increasingly challenging or neglected all together. [6]

Contact trigger use also continues to be justified because there are some situations, such as sheathing a roof, when materials can slide and creep downwards, that rapid firing of guns and even bounce nailing are almost necessary or can really help the process.[4] There is also a perception that sequential triggers will slow production or actually cause repetitive motion injuries; but, none of these have been substantiated, and production times were actually proven to differ less than 1% between triggers in one study. [11]

Prevention and Control

When examining nail gun injuries, and trying to prevent them, and/or reduce their frequency and severity, an epidemiologic approach can be used. This approach looks and the interaction between the environment, the nail gun user, and the nail gun. One tool that is used is called the Haddon’s Matrix, developed by William Haddon in 1970. The matrix lays out factors that contribute to an injury, in pre-event, event, and post-event phases, to help pinpoint intervention areas (See Table). [14]









· Experience level

· Skill level

· Training

· Knowledge of correct work practices

· Awkward postures

· Level of concentration

· Able to speak/read English

· Trigger type

· Safety mechanism function and use

· Type of materials being used

· Defective equipment

· Safety warnings and directions present

· Weather conditions

· Construction and building activity

· Work at heights

· Skill of other employees

· Distractions

· Jobsite housekeeping

· Manufacturers decisions on trigger type

· Type of trigger shipped with gun

· Knowledge of employer on nail gun risks

· Time spent training employees

· Union vs. non-union

· Commercial vs. residential construction


· Use of PPE

· Knowledge of potential causes of gun ( mis)fire

· How to hold and position hands and body

· Correct and non-defective PPE

· Safety mechanism

· Trigger type

· Power of the gun

· Weather conditions

· Size of work area

· Proximity of co-workers

· Available resources, knowledge, or concern on part of employers and employees

· Inadequate nail gun maintenance, training, or PPE


· Pain tolerance

· Health status

· Severity of injury

· Location of injury

· Infection

· Lost work time and financial strain

· Emotional damage

· Nail depth

· Nail structure

· Adhesives or coatings

· Distance to medical care

· Hand specialist available

· Specialty care available

· Rehabilitative care available

· Emphasis on injury reporting

· Emphasis on seeking medical care

· Proper care

· Follow-through with care instructions

· Increased medical and workers' compensation rates for employers

Total Losses/Cost

Damage to People

Damage to Equipment

Damage to Physical Environment

Damage to Society

Haddon's Matrix Applied to Nail Gun Injuries

In addition to the matrix, Haddon also developed 10 strategies for injury prevention and control, occurring in the different phases of the injury, to be used for systematic consideration of how to prevent or reduce the impact of any type of injury. There are prevention and control measures that are particularly warranted or successful for nail gun injuries, and several of Haddon’s 10 strategies are particularly applicable. [14] Using the hierarchy of control, engineering strategies are considered first, followed by legislative and administrative, training, and finally personal protective equipment.

Engineering Controls
1. Prevent the Creation of the Hazard in the First Place:
3. Prevent the Release of the Hazard that Already Exists:
4. Modify the Rate or Spatial Distribution of the Hazard From its Source:
7. Modify the Basic Relevant Qualities of the Hazard:

Using engineering control approaches before injuries occur is the best way for prevention, and many of Haddon’s strategies are applicable. Since nail guns will not be eliminated, the next best option is to eliminate the contact trigger through a variety of methods. There is a high prevalence of contact triggers out in the work field, and switching to sequential triggers from contact triggers will produce a substantial decrease in the rate of injury. [6] The majority of nail gun manufacturers offer the sequential trip option on new guns or have kits that will retrofit old guns to sequential triggers. [1] However, the most effective, option would be for manufacturers to stop making contact trip triggers all together, and switch to only making sequential trip triggers. Additionally, safety components should not be made to allow the user to turn them off or override them and turn the gun onto “bounce” or rapid fire mode. Nail gun manufacturers can also make substantial improvements in the weighting, balance, and center of gravity of guns to reduce the risk for nail gun injuries.

Legislative and Administrative Controls
2. Reduce the Amount of Hazard Brought into Being:
4. Modify the Rate or Spatial Distribution of the Hazard From its Source:

Standards, regulations, and policy changes should be used to complement engineering controls to reduce nail gun injuries. A voluntary ANSI standard is not effective enough to promote the change to the sequential trigger, and contact triggers should not be allowed to be shipped in the same box when a new gun is ordered. Mandatory safety or manufacturing requirements need to be in place to force the sequential trigger to the industry norm. Regulations should also define minimum training requirements that would be needed for someone to be adequately aware of hazards, able to recognize hazards, and safely handle and use a nail gun. Vendors and dealers should be held accountable for training and safe use of their products.

3. Prevent the Release of the Hazard that Already Exists:
5. Separate, in Time or Space, the Hazard and that which is to be Protected:
8. Make what is to be Protected more Resistant to the Hazard

Vendors and manufacturers need to ensure instruction and procedures reach end-user, especially in the case of a sale or rental to users unfamiliar with nail guns. Nail gun use should never be assumed to be an unskilled task and training should not be limited to just how to operate and upkeep the tool. Training on proper techniques, safety features, and work practices, such as never pointing the gun at others, not moving around the site with a finger on the trigger, and proper hand placement and body position prevents injuries. It makes people more aware and keeps them out of the direct line of fire in case of accidental discharge or misfire. People also need to know in which situations over penetrations of the materials are likely, and which materials and properties of the materials would make ricochet likely. [4, 6] More training is better, and the best type of training is classroom combined with hands-on. [11]

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Strained Overhead Position, and Co-Worker in Direct Line of Fire in the Event of Over-Pentration of Wood

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Work at Heights, Potential for Trips, Slips, or Fall, and Employee has Finger on the Trigger When Not Firing Gun

Training should specifically target younger and less experienced employees. Since the nail gun is easy to use, it is often given to these employees soon after coming on the job, so early and immediate training is needed to prevent injuries. [6]

Currently, the value and injury reduction of training is only half as effective as changing from contact to sequential trigger, however, as sequential triggers become more commonplace, the impact of proper and effective training on injury reduction will become more noticeable. [6]

Personal Protective Equipment
6. Separate the Hazard and that which is to be Protected by Interposition of a Material Barrier:
8. Make what is to be Protected more Resistant to the Hazard

Regardless of trigger type, appropriate personal protective equipment (PPE) should always be worn on the jobsite or when working with or around nail guns. In the event of an unintentional or misdirected discharge of a nail, safety glasses and steel toe boots or heavy work shoes will protect the employee from serious injury, or prevent the injury all together from the parts of the body that are shielded. Eye protection is especially important due to the catastrophic nature of eye injuries. Hearing protection is also necessary due to possibility of exceeding allowable noise limits with prolonged nail gun use.

After an Injury
9. Begin to Counter the Damage Already Done by Environmental Hazards:
10. Stabilize, Repair, and Rehabilitate the Object of Damage:

Special emphasis needs to be made to employees on reporting nail gun injuries and seeking timely medical care. All nail gun injuries should be professionally cleaned, and more severe injuries to the hand should be referred to a hand specialist. All follow-up care and rehabilitative directions must be followed.

Continued Data and Research Needs

After examining the nail gun injury problem and using an epidemiologic approach to look at interactions of many various factors, there are clearly some areas that require more attention. One area is the continued emphasis on removing the contact trigger from the market, through a combination of engineering controls, legislation, and overall user education. A second area is the accurate capture and collection of nail gun injury data, since nail gun injuries are so highly underreported, and directly measuring hours of exposure is difficult. A simple examination of workers’ compensation data, medical records, or employment records may not accurately depict the magnitude of the problem. Continued use of active surveillance, similar to Lipscomb’s various studies, [4, 6, 11] should be used to best capture nail gun injury data. A third area that would be interesting to research further would be the magnitude of nail gun injuries with the at-home, non-occupational nail gun user, and how effective strategies are in controlling their rate of injury. A final area for continued research includes non-unionized, small contractor, residential, or non-native populations in construction. There is very little data on these populations due to the structure of work, employee turnover, the unique occupational culture, and the research challenges that are present. The majority of those exposed are within these populations, so learning the true magnitude of their nail gun injury problem, along with the effectiveness of controls or interventions on these populations is extremely important.


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Website Information

Author Information

Katie Schofield, MEHS, CSP, ARM, CHST


PhD Student
Occupational Injury Prevention Research Training Program
University of Minnesota

Loss Control Representative
The Builders Group

Master of Environmental Health & Safety
University of Minnesota Duluth

This website is based on a paper written to fulfill requirements for the class Public Health 6120: Injury Prevention in the Workplace, Community, and Home. Students were asked to select an injury problem related to the workplace, community, or home and discuss the magnitude of the problem and related issues. Students were also to use an epidemiological approach in developing strategies for prevention and control of injury, specifically incorporating Haddon's Matrix and Haddon's Ten Strategies.

The majority of pictures on this website were taken on my visits to jobsites around the Twin Cities Metro and state of Minnesota.

Additional photo contributors:
John Primozich, MEHS, CSP, ARM
Adam Tripp, MEHS