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Applied Ergonomics 38 (2007) 9197 www.elsevier.com/locate/apergo

Comparing the results of ve lifting analysis tools

Steven J. Russell, Lori Winnemuller, Janice E. Camp, Peter W. Johnson
Department of Environmental and Occupational Health Sciences, University of Washington, 4225 Roosevelt Way NE #100, Campus Box 354695, Seattle, WA 98195-6099, USA Received 3 June 2004; accepted 5 December 2005

Abstract The objective of this study was to compare the results of the NIOSH, ACGIH TLV, Snook, 3DSSPP and WA L&I lifting assessment instruments when applied to a uniform task (lifting and lowering milk cases with capacities of 15 and 23 l). To enable comparisons between the various lifting assessment instruments, the outputs of each method were converted to an exposure index similar to the NIOSH Lifting Index. All instruments showed higher exposures associated with lifting the 23 l cases versus the 15 l cases. The NIOSH, ACGIH TLV and Snook methods were similar in their results with respect to the pattern of exposure over various height levels and the differences in exposures associated with lifting 15 and 23 l cases. However, the WA L&I and 3DSSPP predicted substantially lower exposures. The reasons for instrument differences are presented so that practitioners can better select the methods they need and interpret the results appropriately. r 2006 Elsevier Ltd. All rights reserved.
Keywords: Lifting analysis; Ergonomics assessment methods; Materials handling

1. Introduction The prevalence and severity of work-related back injuries is a signicant problem; in the State of Washington, self-insured workers compensation claims data for the period of 19922000 shows that 51.5% of compensable closed claims were for back disorders (Safety and Health Assessment and Research for Prevention (SHARP), 2002). Heavy lifting has been identied as a major risk factor for the development of back injuries (Marras et al., 1993; Hildebrandt, 1987). Ergonomists have long sought ways to objectively quantify the exposures associated with heavy lifting in order to more accurately anticipate high risk activities and prescribe appropriate interventions (Dempsey, 1998). Consequently, numerous lifting analysis tools have emerged with each one having different inputs, outputs, and subsequent interpretive capacities. These tools, while advancing the ability to characterize, quantify and predict the exposures, nevertheless retain a degree of uncertainty, incompleteness, and differing attributes that
Corresponding author. Tel.: +1 253 846 4689; fax: +1 253 846 4200.

E-mail address: steven.j.russell2@boeing.com (S.J. Russell). 0003-6870/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.apergo.2005.12.006

practitioners need to be aware of when using and interpreting results (Fallentin et al., 2001; Janowitz et al., 2005). Five lifting analysis methods were chosen for comparison: the revised 1991 National Institute of Occupational Safety and Health lifting equation (NIOSH) (Waters et al., 1993), the American Conference of Governmental Industrial Hygienists lifting threshold limit values (ACGIH TLV) (ACGIH, 2005), the Liberty Mutual Snook Lifting Tables (Snook)(Snook and Ciriello, 1991), the University of Michigan 3D static strength prediction program (3DSSPP) (University of Michigan, 2001) and the Washington State ergonomics rule lifting calculator (WA L&I) (WAC, 2000a, b). Each of the instruments has unique attributes that make it desirable for this study. The NIOSH instrument was selected because it is universally recognized and widely used throughout the world. The ACGIH TLV tool is largely based on the NIOSH instrument, but is designed to be more expedient than NIOSH. It is the most recently developed tool and used mostly within the US. The Snook, a psychophysical-based tool, is used by US practitioners to obtain design guidelines. The 3DSSPP was chosen because

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of its unique low back compression force predictive capabilities. Finally, the WA L&I, which is based on the NIOSH methodology, was designed for use as a regulatory instrument in Washington state and was designed to identify the highest risk jobs. The specicity and resolution of inputs (i.e., angles, distances) varies across these tools (Table 1). All methods derive an outcome that attempts to predict the relative safety and/or risk of a lift for given populations, but use different terminology and parameters to do so. All instruments are limited in their capacity to incorporate the degree of acceleration/deceleration, shear forces, ambient temperature extremes, one-handed lifts, the lifting of unstable and odd-shaped objects, or the continuous three-dimensional (3D) forces and moments about the spine into their calculations (Fathallah, 1997). While the literature is replete with descriptions of individual instruments, quantitative comparisons between the respective methods is less complete (Marklin and Wilzbacher, 1999; Marras et al., 1999; Waters et al., 1998). The aim of our study was to compare the results of the ve lifting analyses of a common lifting task in order to clarify the similarities and differences between instruments and provide guidance to ergonomics practitioners. 2. Methods 2.1. Work parameters A regional grocery store chain requested assistance to assess the potential impact of switching from 23 l cases to 15 l containers in their stocking operations. This opportunity was used to compare ve instruments used for assessing musculoskeletal exposures. Baseline data for the analyses were collected by interviewing, observing and videotaping an experienced 95th percentile (for height) male worker while he stocked the dairy cooler with milk shipped in 23 l cases. Anatomical landmarks required for
Table 1 Input variables and outcomes of ve lifting assessment tools Input variables Anthropometry Height and weight Joint angles Maximum lift (kg) Frequency Duration Lift origin (H&V) Destination (H&V) Travel distance Coupling Asymmetry Outcomes WA L&I X NIOSH

use in ACGIH TLV, Snook and WA L&I were based on the 95th percentile measurements of US males: stature 187.6 cm; shoulder height156.5 cm; waist height 116.8 cm; knuckle height82.8 cm; knee height54.6 cm; mid-shin height31.5 cm and ankle-to-toe distance 22.5 cm (PeopleSize, 1997; Pheasant, 1996). The subjectspecic height (187.6 cm) and weight (83.9 kg) were used to compute the 3DSSPP results. Lifting frequencies were estimated from typical deliveries to the stock room during an 8 h shift. The same lifting parameters were used as inputs across all the instruments analyzed. Each 15 l case weighed 17 kg and measured 33 cm wide by 33 cm long by 28 cm tall. Each 23 l case weighed 26 kg and was 33 cm wide by 48 cm long by 28 cm tall. The handles of both of the cases were 25 cm from the bottom of the case. There were thirty 23 l cases and forty-ve 15 l cases to a pallet. Both were delivered and stacked three rows wide, ve cases high and two rows deep for 23 l cases and three rows deep for 15 l cases. The stacks were pulled off the pallets into the storage area and slid into a storage space on the oor. For purposes of stock rotation, space saving or sorting, some or all of the cases in a stack were redistributed to other stacks up to seven-high. Vertical measurements were taken from the oor. The storage cooler where the de-palletizing took place was a constant 1.7 1C. Lifting occurred at a rate of 2 min1 for the 23 l cases and 3 min1 for 15 l cases. Both were for durations p2 h. Despite the different rates and number of lifts between the 15 and 23 l cases, lifts at rates of 2 min1 and 3 min1 fell into the same frequency category on all tools, and as a result, the 15 and 23 l cases used the same frequency multipliers. 2.2. Measurements Consistent values were used in the lifting equations derived from how the subject actually performed the task.

ACGIH TLV X

Snook X

3DSSPP X X X NA

41 X X X

X Lifting limit

23 X X X X X X X

32 X X X

Subject based X X X

X L5/S1 compression force (LB); % strength capable, joint moments

Recommended weight Threshold limit value Design goal; % limit; lifting index strength capable

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S.J. Russell et al. / Applied Ergonomics 38 (2007) 9197 Table 2 Horizontal and vertical measurements used in the analyses for lifting the 15 and 23 l cases Level 15 and 23 l case measurements (cm) Horizontal 1 2 3 4 5 6 7 23 23 30 30 30 30 30 Vertical 25 53 81 109 137 165 193 93

A 23 cm H value was selected for case levels 1 and 2 to reect the observation that most workers would straddle the lower cases to give themselves a mechanical advantage during lifting (NIOSH automatically converts H values of o25 cm to 25 cm). All other levels were assigned a 30 cm value (Table 2). This standardization facilitated comparison between tools rather than focusing on subject-specic performance. The horizontal distance (H) was measured in the sagital plane from the midpoint of the subjects ankles to the center of his hands for all tools except WA L&I. WA L&I measures H from the toes to the hands. Accordingly, the distance from the ankle to the toes for the 95th percentile male, 22.5 cm (PeopleSize, 1997), was subtracted from the ankle-to-hand values for WA L&I calculations. Vertical values were measured from the oor to handleheight at each of the seven levels beginning at 25 cm and continuing at 28 cm intervals (Table 2). The load/trunk asymmetry values relative to the mid-sagital vertical plane (0301) reect the range of movement that was observed during the videotape analysis. 2.3. Instruments (1) The revised 1991 NIOSH is a multiplicative model that uses six weighted variables: horizontal distance, vertical distance, distance traveled, and asymmetry, frequency and coupling measures. NIOSH calculates a recommended weight limit (RWL) and a lifting index (LI) for use in determining the relative risk of injury (Waters et al., 1993). The RWL is thought to be the weight nearly all healthy workers could perform over a substantial period of time (e.g., up to 8 h) without an increased risk of developing lifting-related low back pain (National Institute of Occupational Safety and Health (NIOSH), 1994). The LI is calculated by dividing the weight of the object lifted by the RWL. Because of the uncertainty of the doseresponse relationship between weight lifted and risk of injury, it is not possible to quantify the precise degree of risk associated with varying increments of the LI. However, it is generally

believed that lifting tasks with an LI of greater than 1.0 pose an increased risk for low back pain for some fraction of the workforce (Waters et al., 1993). All 49 possible combinations of milk case movements (seven origins and seven destinations) were analyzed using NIOSH for both the 15 and 23 l cases. The destination portions of the lifts were not evaluated as separate lifts because signicant control was not usually required at the destination. The most favorable coupling variable, 1.0, was also used in the equation. (2) The ACGIH TLV were created to provide guidelines for safe lifting (ACGIH, 2005). The TLVs are categorized by exposure durations (either o2 h/day or 42 h/day), frequency (expressed in number of lifts per hour), height zone (four categories based on anthropometrics) and the horizontal location from the midpoint between the ankle bones (o30, 3060 and 460 cm). The TLVs recommend workplace lifting conditions under which it is believed nearly all workers can be exposed on a daily basis without developing work-related low back and shoulder disorders. (3) The Liberty Mutual Snook lifting tables (Snook) were developed to assist industry in the evaluation and design of manual handling tasks (Snook and Ciriello, 1991). A psychophysical approach was used to determine the maximum acceptable weights and forces for lifting tasks. Suggested parameters for handling tasks are based on experimentally determined weight selection and are displayed in the Snook tables. Thomas Bernards on-line Lift/Lower Analysis Package (Bernard, 2002), which utilizes the Snook tables, was used to calculate the Snook values. The Snook model takes into account the weight of the object lifted, the position of the hands at the origin of the lift/lower (18, 25 or 38 cm), the vertical zone of the lift (oor to knuckle, knuckle to shoulder and above shoulders), the distance of travel (0, 25, 51 or 76 cm) and the frequency of the lift/lower (eight categories from one per 8 h to one per 5 s). The Snook tables provide a design goal, which is a target value (in kg) that represents a lifting force that is acceptable for 75% of women. It is presumed that the greater the percent acceptable, the lower the risk to the population, and that 75% acceptable for women is a good design goal for a mixed workforce. (4) The University of Michigan 3DSSPP predicts a L5/S1 back compression force (BCF) and the percentage of a given population with sufcient strength capability in their elbows, shoulders, ankles, knees and torso to perform lifting tasks. A BCF of 350 kg is comparable to the NIOSH LI of 1.0, which represents the point at which 99% of males and 75% of females are said to be protected from developing lifting-related back pain (Chafn et al., 1999). A BCF of 649 kg is comparable to an LI of 3.0 where 25% of males and 1% of females are said to be protected. The 15 and 23 l milk case lifting postures were modeled based on the H and V values

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Fig. 1. WA L&I H and V values.

used in the other assessment tools and the stature of our subject (187.6 cm, 83.9 kg). The height of the various milk cases provided the vertical hand postures (V) in the 3DSSPP, the width of the milk crates provided the lateral hand distances (33 and 48 cm for 15 and 23 l cases, respectively) and H was 23 cm (case levels 1 and 2) and 30 cm (case levels 37). (5) The WA L&I was one option provided to employers for analyzing lifting exposures as a part of the Washington State Ergonomics Rule that was instituted in 2000 and later rescinded by voter initiative in 2003 (WAC, 2000a, b). This instrument was based on the NIOSH lifting equation with some modications to identify possible high-risk lifts (WAC, RCW 34.05.325.6a, 2000b). It incorporated three multiplicative variables in calculating a suggested Lifting Limit (LL) for a prescribed lift: (1) the horizontal and vertical position of the hands relative to the subjects toes at the origin of the lift (Fig. 1), (2) whether or not the torso is twisted more than 451 while lifting and (3) the frequency and duration of the lifting task. Tasks that exceeded the LL were considered hazardous. This instrument made no provisions for evaluating multiple lifts; consequently, for the purposes of our study, each of the seven heights in this study was assessed separately.

(recommended weight guidelines) for all possible lifting combinations at each level were averaged. The milk case weights of 17 kg (15 l) and 26 kg (23 l) were then divided by the averaged outputs to calculate composite EIs for each level. An EI of 1.0 indicates that the recommended weight equals the case weight; an EI greater than 1.0 indicates to what degree the actual weight exceeds the recommended weight guidelines. Findings from the 3DSSPP have similarly been converted to an exposure index. However, the numerator was the average number of kilograms of BCF calculated by the 3DSSPP, and the denominator was 349 kg (the amount of force indicated as acceptable for 99% of the American male population and 75% of the female population (Chafn et al., 1999). The resulting EI was the relative exposure compared to the acceptable 349 kg of compressive force on the spine. Standard deviations were calculated only for the NIOSH instrument because seven values (for each destination from levels 17) were calculated for each lift; all other instruments had a single value calculated for each lift because they did not include a destination factor in their calculations. The NIOSH single- and multi-task analyses were calculated using a software program developed by Thomas Bernard (2002). A single-task analysis of all lifts was performed so that the lift at each level could be evaluated independently. Single-task and multi-task analyses were performed on a subset of best- and worst-case lifts in order to compare the results of each method. Best-case lifts were those closest to waist-height with the least vertical travel distance (22, 33, 44, 55, 23, 32, 34 and 43), and worst-case lifts were those with the greatest travel distance furthest from waist-height (17, 71, 27, 72, 16, 61, 26 and 62). Average LIs were calculated for the single-task analyses and a Composite LI was derived for the multi-task analyses.

4. Results The NIOSH EIs all exceeded 1.0 (Fig. 2). The average EI for 23 l cases (1.9) was 53% higher than the average EI for the 15 l cases (1.25). As shown in Fig. 2, the EI progressively increased by case level. Exposure indexes ranged from 1.14 to 1.52 for the 15 l cases and from 1.74 to 2.32 for the 23 l cases. The ACGIH TLV EI exceeded 1.0 for all levels with levels 6 and 7 having substantially greater exposures (Fig. 3). When averaged over all levels, the EI was 53% greater for the 23 l cases (range 1.463.75) as compared to 15 l cases (range 0.962.46) with mean EIs at 2.29 and 1.50, respectively. When averaged over all levels, the Snook EIs were all greater than 1.0 with a 34% greater exposure for 23 l cases (range 2.152.76) as compared to the 15 l cases (range 1.582.11) (Fig. 4). The EI was virtually the same for levels

3. Analysis For the purpose of normalizing the tool outcomes so as to compare inter-case level and inter-tool results, the output of each lifting instrument was converted to an exposure index (EI) similar to the NIOSH LI. The outputs

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4.0 3.5 3.0 Exposure Index 2.5

1.79 1.74 1.14 1.15 1.75 1.80 1.18 1.89 1.24 2.05 1.52 1.34 15-liter 23-liter

2.32

2.0
1.17

15 and was higher for levels 6 and 7 for both 15 and 23 l case lifting. The 3DSSPP EI only slightly exceeded 1.0 and only at case level 1. The average exposure for lifting the 23 l cases (range 0.501.25) lifting was 24% higher than that of 15 l lifting (range 0.361.05) (Fig. 5). The WA L&I EI calculations demonstrated that all levels had an exposure index under 1.0 (Fig. 6). The average EI

1.5 1.0 0.5 0.0

4.0 3.5 3.0 Exposure Index 1 2 3 4 Case Level 5 6 7 2.5 2.0 1.5 1.0 0.5 0.0 1
2.46 1.88 1.46 1.23 0.96 1.08 1.08 1.88 1.64 1.64 2.46 1.25 1.05 15-liter 23-liter

Fig. 2. NIOSH lifting equation lifting index per case level.

4.0 3.5 3.0 Exposure Index 2.5 2.0

15-liter 23-liter

3.75

3.75

0.88 0.85

0.76 0.54

0.53 0.5 0.43 0.36

0.55 0.54 0.41 0.41

4 Case Level

Fig. 5. 3DSSPP mean exposure index per case level.

1.5 1.23 1.0 0.5

4.0 3.5 3.0

15-liter 23-liter

4 Case Level

Exposure Index

0.0

2.5 2.0 1.5 1.0

0.87 0.57 0.57 0.87 0.68 0.44 0.44 0.68 0.57 0.87 0.61 0.93 0.61 0.93

Fig. 3. ACGIH Lifting TLV mean exposure index per case level.

4.0 3.5 3.0 Exposure Index 2.5

2.15 2.15 1.58 2.11 15-liter 23-liter 2.76

0.5 0.0 1 2

4 Case Level

Fig. 6. WA L&I Lifting Calculation mean exposure index per case level.

2.0
1.58

1.5 1.0 0.5 0.0 Case Levels 1-3 Case Levels 4-5 Case Levels 6-7
Fig. 4. Snook Lifting Tables mean exposure index per case level.

Table 3 Comparison of NIOSH single-task and multi-task LIs for worst- and bestcase lifts 23 l (worstcase) Single-task (average LI) Multi-task (composite LI) 2.3 2.3 15 l (worstcase) 1.5 2.1 23 l (bestcase) 1.5 2.2 15 l (bestcase) 1.0 1.4

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for 23 l cases (0.83) was 54% higher than the average EI for 15 l cases (0.54). As outlined in the analysis section, single- and multi-task NIOSH analyses for selected worst- and best-case lifts were conducted and the average and composite LIs were calculated (Table 3). The multi-task method predicted a 40% greater exposure for 15 l case lifting and an 18% greater exposure for 23 l lifting when compared to the single-task approach. 5. Discussion The primary aim of this study was to compare outcomes of ve lifting assessment instruments when applied to a uniform task (milk case lifting). As expected, all instruments predicted a higher exposure when lifting the heavier 23 l cases versus the 15 l cases, although the extent of the disparity varied between instruments. In four of the ve instruments (all but 3DSSPP), lifting cases from the lowest level resulted in exposure indexes that were virtually the same or less than the mid-range lifts (levels 3 and 4). In contrast, the 3DSSPP showed a reverse pattern, with lifts from the lowest levels having the highest exposure. It appears that the vertical distance multipliers are weighted differently in the formula-based methods compared to the 3DSSPP. The exposures were found to be greatest at the highest levels (6 and 7) with three reecting the expected increased biomechanical demand of lifting above shoulder height. The ACGIH TLV had a relatively higher exposure rating for the level 6 and 7 lifts, and weighted lifts above the shoulder more than the other methods. Had we incorporated shoulder strength capabilities into the exposure index calculation for the 3DSSPP, the results would likely have shown a pattern more similar to the other tools. Shoulder moment information is separate from back compression force analysis in the 3DSSPP methodology and was not included in our modeling. While WA L&I was based on NIOSH research, it was designed as a regulatory tool to provide a reasonable balance between simplicity and predictive value for identifying and controlling lifting hazards, and as such, produces outcomes that are less restrictive than NIOSH (WAC, RCW 34.05.325.6a, 2000b). The WA L&I lifting limits, which have an EI of 1.0, are approximately equivalent to a NIOSH LI of 2.0 for stressful near-reach lifts in that the regulatory focus was to identify moderateto high-exposure lifts only (WAC, RCW 34.05.325.6a, 2000b). Our ndings were consistent with this design in that the mean EI for NIOSH was slightly more than double the mean WA L&I EI. It would be misleading to interpret the lower composite EI for WA L&I as predictive of less exposure than NIOSH when, in fact, it is similar. The lower composite EI obtained from the 3DSSPP may in part be due to the fact that the metabolic loads and cumulative effect of repetitive compressive forces are not accounted for by the 3DSSPP. As discussed earlier, although not part of this study, had shoulder moments

been taken into account this would certainly have modied the exposure predicted by the 3DSSPP. In addition, the 3DSSPP output is based on a static analysis, which may have also contributed to the underestimation of the exposure (McGill and Norman, 1985). Dynamic forces during a lift are reported to increase L5/S1 compressive forces from 21% to 70% compared to a static lifting analysis (Chafn et al., 1999). The results of the NIOSH single-task and multi-task analyses indicate that the latter predicts greater exposure than the former (Table 3). The multi-task calculation accounts for the cumulative effects of successive lifts, whereas the single-task calculation does not. The implication is that the single-task calculation may underestimate the actual risk of multi-task lifting. However, calculating the multi-task composite LI is complex and cumbersome. The question arises as to which lifting instrument is most accurate. There is generally a void in the literature with regard to the ability of the various lifting assessment methods to accurately predict injuries (van der Beek et al., 2005; Dempsey and Mathiassen, 2006). However, Marras et al. (1999) reported that NIOSH correctly identied 73% of the high-risk jobs and that Snook identied only 40% of high-risk jobs (based on comparing test predictions with the history of actual job injuries). Marras also reported that Snook more accurately predicted low- and moderate-risk jobs than NIOSH. It was outside the scope of this project to validate any of the instruments or to determine their ability to predict adverse health outcomes. Rather, we determined that the ve instruments tested had some similarities as well as some not so obvious dissimilarities; however, the need exists to validate the utility of these tools for correctly identifying adverse lifting situations that lead to injuries. The practitioner must choose the instrument that best suits the complexity of the task, the users skill level and the relevance of the instruments output to the problem at hand. While the exposures determined by the ACGIH TLV, NIOSH and Snook were similar, NIOSH was most conducive for understanding the impact of inputs or changing lifting inputs on lifting exposures. ACGIH TLV and Snook were easier to implement in the eld than NIOSH, but not as conducive to experimentation with different inputs. Also, NIOSH outcomes are inuenced by incremental changes in inputs; in ACGIH TLV and Snook methods, incremental changes in input values do not necessarily inuence outcomes unless they cross certain threshold values. The 3DSSPP was more complex, does not account for lifting frequency and the back compression results used without shoulder moment information was less sensitive to exposures associated with lifts above shoulder height. However, it is the only tool that incorporates individual height and weight into its calculations. The WA L&I was designed to identify only moderate- to highexposure lifting. It is prudent for practitioners to fully understand the strengths, limitations and underlying assumptions of the exposure assessment tools used in order

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to accurately formulate, if not temper, their interpretation of assessment ndings. 5.1. Limitations of the study The level of exposures calculated by the assessment tools evaluated may underestimate the actual exposure because of the relatively cold environment in which the study task was performed. Also not taken into account were the constrained lifting conditions that can be a part of the job when working in tight spaces. However, the absence or presence of lifting factors was consistent across the instruments analyzed in this study. The study also considered only lifting activities which were modeled after a 95th percentile male, which may have inuenced how the instruments compared with one another, although similar trends were found by the authors using smaller anthropometry. Finally, the study utilized only multi-level repetitive lifting in the analyses; lifting tasks with alternate parameters may generate different results. 6. Conclusion This study found that NIOSH, ACGIH TLV and Snook instruments provided similar results when assessing musculoskeletal exposures associated with a lifting task. The WA L&I instrument predicted only low to moderate exposures for lifts that were deemed hazardous by the above three methods. The 3DSSPP low back compression force analysis differed from these four tools in that it showed a reverse pattern of exposure prediction relative to lifting height and like the WA L&I indicated that the exposure was substantially lower. When considering the complexity of performing these calculations, the ACGIH TLV, Snook and WA L&I were simpler to use since they required fewer inputs than the six inputs needed for the NIOSH lifting equation, but NIOSH offered a greater range of interpretive capabilities in order to help determine what aspects of the lift would most benet from changes. Acknowledgments Funding was supplied in part by the Washington State Medical Aid and Accident Fund and the University of Washington Department of Environmental and Occupational Health Sciences. References
ACGIH (American Conference of Governmental Industrial Hygienists), 2005. TLVs and BEIs: Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices. Cincinnati, OH. Bernard, T.E., 2002. Analysis Tools for Ergonomists. http://hsc.usf.edu/ tbernard/ergotools/.

Chafn, D.B., Andersson, G., Martin, B.J., 1999. , third ed. Occupational Biomechanics, vol. xvii. Wiley-Interscience Publication, New York, 579pp. Dempsey, P.G., 1998. A critical review of biomechanical, epidemiological, physiological and psychophysical criteria for designing manual materials handling tasks. Ergonomics 41 (1), 7388. Dempsey, P.G., Mathiassen, S.E., 2006. On the evolution of task-based analysis of manual materials handling, and its applicability in contemporary ergonomics. Appl. Ergonom. 37, 3343. Fallentin, N., Viikari-Juntura, E., Waersted, M., Kilbom, A., 2001. Evaluation of physical workload standards and guidelines from a Nordic perspective. Scand. J. Work Environ. Health 27 (Suppl 2), 152. Fathallah, F., 1997. A method for measuring external spinal loads during unconstrained free-dynamic lifting. J. Biomech. 30 (9), 975978. Hildebrandt, V.H., 1987. A review of epidemiologic research on risk factors of low back pain. In: Buckle, P. (Ed.), Musculoskeletal Disorders at Work. Taylor & Francis, London, pp. 916. Janowitz, I.L., Gillen, M., Ryan, G., Rempel, D., Trupin, L., Swig, L., Mullen, K., Rugulies, R., Blanc, P.D., 2005. Measuring the physical demands of work in hospital settings: design and implementation of an ergonomics assessment. Appl. Ergonom. 37. Marklin, R.W., Wilzbacher, J.R., 1999. Four assessment tools of ergonomics interventions: case study at an electric utilitys warehouse system. Am. Ind. Hyg. Assoc. J. 60, 777784. Marras, W.S., Lavender, S.A., Leurgans, S.E., Rajulu, S.L., Allread, W.G., Fathallah, M.S., Ferguson, S.A., 1993. The role of dynamic three-dimensional trunk motion in occupationally related low back disordersthe effects of workplace factors, trunk position, and trunk motion characteristics on risk of injury. Spine 18 (5), 617628. Marras, W.S., Fine, L.J., Ferguson, S.A., Waters, T.R., 1999. The effectiveness of commonly used lifting assessment methods to identify industrial jobs associated with elevated risk of low-back disorders. Ergonomics 42 (1), 229245. McGill, S.M., Norman, R.W., 1985. Dynamically and statically determined low back moments during lifting. J. Biomech. 18 (12), 877885. National Institute of Occupational Safety and Health (NIOSH), 1994. Applications Manual for the Revised NIOSH Lifting Equation. PeopleSize, 1997. Open Ergonomics Ltd., Loughborough Technology Center, Epinal Way, Loughborough, LE11 0QE, UK. Pheasant, S.T., 1996. Bodyspace, second ed. Taylor and Francis, London. Safety and Health Assessment and Research for Prevention (SHARP), 2002. Work-related Musculoskeletal Disorders of the Neck, Back, and Upper Extremity in Washington State, 19922002. Olympia, WA. Snook, S.H., Ciriello, V.M., 1991. The design of manual handling tasks: revised tables of maximum acceptable weights and forces. Ergonomics 34 (9), 11971213. University of Michigan Center for Ergonomics, 2001. 3D Static Strength Prediction Program Users Manual. p. 81. van der Beek, A.J., Mathiassen, E.S., Windhorst, J., Burdorf, A., 2005. An evaluation of methods assessing the physical demands of manual lifting in scaffolding. Appl. Ergonom. 36, 213222. WAC 296-62-051, 2000a. Washington State Ergonomics Rule. Bureau of Labor and Industries, Olympia, Washington. WAC 296-62-051, 2000b. Explanatory Statement (RCW 34.05.325.6a). Washington State Ergonomics Rule. Bureau of Labor and Industries, Olympia, Washington, pp. 8386. Waters, T.R., Putz-Anderson, V., Garg, A., Fine, L.J., 1993. Revised NIOSH equation for the design and evaluation of manual lifting tasks. Ergonomics 36 (7), 749776. Waters, T.R., Putz-Anderson, V., Baron, S., 1998. Methods for assessing the physical demands of manual lifting: a review and case study from warehousing. Am. Ind. Hyg. Assoc. J. 58, 871881.