Continued progress in the prevention of nail gun injuries among apprentice
carpenters: What will it take to see wider spread injury reductions?☆
Hester J. Lipscomba,⁎, James Nolanb, Dennis Pattersonb, John M. Dementa
aDivision of Occupational and Environmental Medicine, Duke University Medical Center, Box 3834, Durham, N.C. 27710
bCarpenters District Council of Greater St Louis and Vicinity, St. Louis, Missouri
a b s t r a c ta r t i c l e i n f o
Available online 18 April 2010
Problem: Nail guns are a common source of acute, and potentially serious, injury in residential construction.
Method: Data on nail gun injuries, hours worked and hours of tool use were collected in 2008 from union
apprentice carpenters (n=464) through classroom surveys; this completed four years of serial cross-
sectional data collection from apprentices. A predictive model of injury risk was constructed using Poisson
regression. Results: Injury rates declined 55% from baseline measures in 2005 with early training and
increased use of tools with sequential actuation. Injury rates declined among users of tools with both
actuation systems, but the rates of injury were consistently twice as high among those using tools with
contact trip triggers. Discussion and impact: Nail gun injuries can be reduced markedly through early training
and use of tools with sequential actuation. These successful efforts need to be diffused broadly, including to
the non-union sector.
© 2010 National Safety Council and Elsevier Ltd. All rights reserved.
Lack of training and use of tools with contact triggers are known
risk factors for acute traumatic nail gun injuries in wood frame
construction (Lipscomb, Dement, Nolan, & Patterson, 2006; Lipscomb,
Nolan, Patterson, & Dement, 2008). Contact triggers allow the tool to
discharge a nail anytime the nose piece of the gun and the trigger are
both depressed. This allows rapid fire nailing commonly referred to as
“bump nailing” by workers; it also allows nails to be discharged
inadvertently following the recoil associated with firing of the tool
when the worker still has his or her finger on the trigger. In contrast,
the sequential actuation system designed to prevent non-intended
firing requires that the nose element be depressed before the trigger
in order for a nail to be discharged. Because the center of gravity of the
tool is located at the trigger, it is natural for workers to carry the gun
with a finger on the trigger (Consumer Product Safety Commission,
2002). The sequential actuation also prevents workers from shooting
themselves or a co-worker if the nose of the gun bumps against
someone while it is being carried in this manner. While residential
carpenters typically supply their own hand tools, power tools such as
pneumatic nail guns are usually supplied by the contractor or the
business owner for whom the carpenter works. Because there are
currently no safety regulations that require the use of tools with the
sequential trigger, this necessitates involvement of owners to reduce
dangerous exposures based on the tool actuation systems that they
Union carpenters spend about four years completing their
apprentice training. During this time they typically spend two
weeks twice a year in their apprenticeship school where they receive
both classroom and shop experiences designed primarily to teach
skills, but also to address safety. The remainder of their time is spent
on job sites where they work under the supervision of journeymen
carpenters. Nail guns have become a very common tool in residential
woodframeconstruction. The toolsare easyto operateandtheir useis
common even among very inexperienced workers (Lipscomb,
Dement, Nolan, & Patterson, 2003; Lipscomb et al., 2006, 2008). We
previously reported injury reductions among carpenter apprentices
through access to early training and to tools with sequential triggers
(Lipscomb et al., 2008). In this report we present findings from the
fourth year of follow-up among this high risk group following an
additional year of effort to reduce traumatic injuries caused by
pneumatic nail guns.
2. Materials and methods
2.1. The population and data collection procedures
In 2008, as in three previous years, data were collected from union
apprentice carpenters enrolled in two training programs in the
Midwest for a six-month period. The collection of data for only six
Journal of Safety Research 41 (2010) 241–245
☆ Funding: This work was supported by a cooperative agreement between the Center
for Construction Research and Training (CPWR) and the National Institute for
Occupational Safety and Health (1 U54 OH008307-02).
⁎ Corresponding author. Tel.: +1 919 684 8175; fax: +1 919 286 1620.
E-mail address: email@example.com (H.J. Lipscomb).
0022-4375/$ – see front matter © 2010 National Safety Council and Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
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months avoided asking the same apprentice for data more than once
per year as they cycled through the training program. During this
period of time(2005-2008) effortswere underway to providetraining
in safe nail gun use early in their training program. Through
collaboration with the union and the local homebuilders associations,
access to the safer triggering mechanism was encouraged among local
contractors who hired these apprentice carpenters.
Two journeymen carpenters visited classrooms of the apprentices,
explained the study, and asked apprentices to complete anonymous
surveys. Apprentices were asked to report nail gun injuries they had
experienced as well as the hours worked in residential carpentry in
the last year and an estimate of hours of nail gun use by triggering
mechanism. They were also asked to report training they had in nail
gun use and safety, including classroom experiences and on-the-job
training throughmultiple venues includingtoolboxtalks, moreformal
contractor training programs, and mentoring. All procedures were
approved by the institutional review boards at Duke University
Medical Center and the Center for Construction Research and Training
2.2. Data analyses
Four different outcome measures were used in these analyses.
First, we calculated lifetime and 12-month injury prevalence of nail
gun injuries using data from all apprentices surveyed; prevalence
measures were expressed as a proportion of the surveyed population.
Next crude injury rates (incidence density) expressed as injuries per
200,000 hours worked were calculated; these calculations included
only residential carpentry hours and allow some comparison to
overall injury rates reported through national sources such as the
Bureau of Labor Statistics. Confidence intervals (CI) were calculated
assuming a Poisson distribution (Haenzel, Loveland, & Sirken, 1962).
In the third measure, injury rates were estimated based on actual
hours of tool use overall and by triggering mechanism. These rates
were based on injuries that occurred when the apprentice was
actually using the tool (omitting situations in which the apprentice
was injured by a co-worker) in order to use comparable numerators
and denominators in our rate calculation. These rates were expressed
as injuries per 10,000 hours of tool use. In the event the apprentice
reported more than one injury, analyses were limited to the more
recent event. Hours of exposure and injury events were stratified by
time in the union and time in the trade, trigger mechanism on the tool
being used, and training in tool use before injury. Crude injury rates
were expressed as injuries per 10,000 hours of tool use. Adjusted rate
ratios were calculated using Poisson regression (Nizim, 2000).
Covariates of interest in the predictive model included time in the
union, time in the trade, triggering mechanism on the tool being used,
were retained in the model based on the likelihood ratio statistic or if
their removal changed other risk factors 15% or more. Using these
criteria no variables were excluded from the model with a p-value of
less than 0.20 (Type III statistic, SAS, Version 8.2).
Finally, the population attributable risk percent was calculated
(Hennekens & Buring, 1987) using the rate ratios and the reported
estimates of exposure to pneumatic nail guns before training and by
actuationsystemonthetools beingused.This measureis calculatedas
PAR%=Pt (RR-1)/Pt(RR-1)+1 *100, where Pt represents the prev-
alence of the exposure in the population based on the proportion of
exposed hours used in the incidence density rates and RR is the rate
ratio. The PAR% provides a comparison of the relative proportion of
injuries that could be prevented in this population based on removal
of the risk factor; in this case by providing training before injury and
tools with sequential triggering mechanisms.
These analyses mirrored our earlier reports from these appren-
ticeship programs allowing us to compare each of these metrics to
those reported previously for 2005, 2006, and 2007 (Lipscomb et al.,
2006, 2008). Data from the questionnaires were entered and stored in
an ACCESS database (Microsoft, 2007) created in EpiInfo Version 3.3.2
(CDC, 2005) and transferred to SAS Version 8.2 (SAS Institute, 1999-
2001) for analyses.
Data were collected from 464 carpenter apprentices through
anonymous classroom surveys, adding to surveys collected in 2005
(n=654), 2006 (N=818), and 2007 (n=490) previously reported
(Lipscomb et al., 2008). The response rate among the apprentices
approached was over 95% in each year. These apprentices reported
having experienced between zero and four nail gun injuries with a
mean of 0.32 and a median of zero. Lifetime prevalence of injury was
22.6% and 12-month prevalence was 13%; both have declined steadily
overtime (Fig. 1). The majority of the injuries were self-inflicted, but
12% were caused by another worker who was using the nail gun.
Two-hundred fifty-nine (259) apprentice carpenters worked
276,294 residential hours in 2008 and 35 of them experienced a nail
gun injury; the incidence density injury rate was 25.2 (95% CI 17.5,
35.0) per 200,000 hours worked in residential carpentry. The rate of
injuries for which medical care above first aid was sought was 16.6
(95% CI 10.5, 24.9) and the rate of injuries for which time was lost
beyond the day of injury was 4.3 (95% 1.6, 9.0).
Based on estimates of actual tool use, injury rates were 1.3 (95% CI
0.9, 1.8) per 10,000 hours of use. As with the prevalence measures,
injury rates have declined since 2005 (Fig. 2). The distribution of
injuries and hours worked are presented in Table 1 with the
Fig. 1. Reported prevalence of nail gun injuries by year among apprentice carpenters,
Carpenters District Council of Greater St. Louis and Vicinity, 2005-2008. 12-month
prevalence limited to individuals who worked residential hours in the last year.
Fig. 2. Nail gun injury rates (and 95% confidence intervals) per 10,000 hours of tool use,
apprentice carpenters, Carpenters District Council of Greater St. Louis and Vicinity,
H.J. Lipscomb et al. / Journal of Safety Research 41 (2010) 241–245
corresponding rates and rate ratios. In multivariate analyses,
individuals who used tools with contact triggers and those who had
not had training both had a twofold risk of injury compared to their
co-workers who used tools with sequential triggers and who had
training. When considering training and trigger mechanism on the
tools thecarpentersused, timein thetrade andtimein the unionwere
not significant predictors of injury. These rate estimates are based on
184 individuals who reported hours worked in residential carpentry
in the last year and hours of nail gun use by triggering mechanism; 18
experienced nail gun injuries. These individuals were similar to those
who did not report hours of use based on their time in the union and
time in the trade.
For the first time, in 2007 more than half of the nail gun exposure
time in this population was with the sequential trigger mechanism
(Fig. 3); this increased to 61% in 2008. In this union environment most
of the apprentices received some training in tool use prior to injury
even in 2005, but through efforts at their school as well as through
contractor training efforts, the proportion injured before they receive
training declined to 10% in 2008. Based on PAR% calculations, 9.2% of
nail gun injuries in this population would be prevented by training
before injury while 30.0% would be prevented by switching to tools
with sequential actuation.
Five injuries associated with repetitive use were reported in 2008,
including four among users of nail guns with contact trip triggers and
one in a user of a tool with sequential actuation, these included:
tendonitis, hand stiffness, limited mobility in a finger, and carpal
tunnel syndrome. The associated rates were 0.12 (95% CI 0.003, 0.67)
and 0.73 (95% CI 0.15, 2.1) for sequential and contact trip trigger use,
These data demonstrate significant progress in reducing acute
injuries among union carpenters enrolled in apprenticeship training at
two schools in the Midwest between 2005 and 2008 using a variety of
metrics to monitor morbidity. Lifetime and 12-month prevalence rates
declined as did injury rates based on hours of work in residential
carpentry. Injury rates based on estimates of actual tool use declined
55%. The latter measure obviously used a better denominator to
These reductions in injuries over a four-year period were seen as
more apprentices received early training in tool use and as they had
increasing access to tools with the safer sequential trigger mechanism.
In each year the risk of injury was twice as high among carpenters who
used tools with contact trip triggers and among those without training.
As measured in the PAR% estimates, consistently switching to the safer
sequential triggering mechanism would make more impact on the
musculoskeletal problems was observed as use of tools with sequential
trigger is pulled in order to discharge a nail, became more common.
These disorders were rarely reported and our estimates are quite
six times higher than that associated with use of tools with sequential
triggers.Sincethis groupisnowreportingover60% oftheirnailingtime
with the sequential trigger, they are a good population for continued
active surveillance of potential musculoskeletal concerns.
It is of interest that we observed an increase in the rate of injuries
for which the apprentices sought medical care over time and we saw
more injuries reported to workers’ compensation. We attribute this to
the increased attention given to this common injury, including
encouragement by instructors for the apprentices to seek appropriate
care. Apprentices previously reported failure to report to workers’
compensation for a variety of reasons including pressure from peers
to accept nail gun injuries as the norm, pressure from employers or
supervisors not to report the injury, and lack of perceived seriousness
of a number of injuries (Lipscomb, Nolan, Patterson, & Dement, 2010).
Still, it is of note that despite the fact that only 43% of those who
sought medical care for their injury reported it through the workers’
compensation system, the injury rates are quite high compared to
reports through the BLS. For example, in 2005 BLS estimated rates of
non-fatal injuries and illnesses with days away from work among
carpenters to be 2.5 per 100 full-time workers (CPWR, 2007), yet
these apprentices reported nail gun injuries that required at least a
day away from work at the rate of 4.3 per 100 full-time workers.
We have acknowledged before that our measures are based on
serial cross-sectional data from self-reports of apprentice carpenters
(Lipscomb et al., 2006, 2008). This was a situation where use of a
randomized trial was not feasible for numerous reasons. Contractors
are responsible for the purchase of these pneumatic tools and the
safety of their own workforce. Apprentices often work for more than
one employer before finishing school, which would create significant
potential contamination of groups. Training for apprentices was
already underway at the apprenticeship school and among some
contractors. Given that we previously saw reduced risk with
increasing time in the union and in the trade, we do not believe
that longitudinal follow-up of a cohort of apprentices would have
been as useful as these data. While we acknowledge there is likely
Stratified rates, rate ratios, and adjusted rate ratios of self-inflicted nail gun injuries
based on hours of tool use among apprentice carpenters, Carpenters District Council of
Greater St. Louis and Vicinity, 2008.
Injuries Hours of
Ratesa(95% CI)Rate Ratios
Time in union
Time in trade
1.7 (0.35, 5.0)
1.5 (0.78, 2.6)
0.75 (0.16, 2.2)
3.6 (0.44, 13.0) 3.6
1.2 (0.39, 2.8)
1.0 (0.48, 1.8)
2.0 (1.0, 3.6)
0.82 (0.33, 1.7)
2.1 (0.77, 5.5)
2.1 (0.41, 6.4)
1.0 (0.53, 1.7)
1.9 (0.19, 1.4)
aRates are expressed per 10,000 hours of tool use.
bPoisson regression results.
Fig. 3. Proportion of hours of tool use with training and sequential actuation nail guns
by year, apprentice carpenters, 2005-2008.
H.J. Lipscomb et al. / Journal of Safety Research 41 (2010) 241–245
some error in the actual recall of hours of tool use, we do not know of
any reason that the recall would be differential based on triggering
mechanism; and we believe the relative risk measures are reasonable
and that the data overall provide strong evidence of effectiveness of
training and sequential trigger use in this population of apprentices
The data from this last year of collection are not as robust as those
collected earlier; the hours of residential work were over 60% less
than what they had been among apprentices surveyed in 2005 at
baseline, reflecting the effect of the economic decline on residential
building. Consequently, our estimates of risk are less precise.
However, we emphasize that the strength of these data lie in the
patterns over time, rather than statistical significance or even
precision, which demonstrate marked and consistent decline in
rates of injury over a four-year period as sequential trigger use
expanded to the majority of residential work hours and the vast
majority of these apprentices received some training in tool use
before they experienced an injury.
As we mentioned earlier, training in the apprenticeship school and
among some contractors had begun prior to our observation of this
group in response to earlier reports of high injury rates among
apprentices (Lipscomb et al., 2003). We do not have measures of the
quality of the training received and the exact school curriculum
continues to evolve due to competing demands and priorities.
However, this is the reality of the world in which these apprentices
and their instructors function. Furthermore, it is obvious that neither
construction skills nor safety can be comprehensively addressed in
school training of these apprentices. In fact, by design in the union
environment of apprenticeship training as well as out of necessity,
some of that responsibility falls to journeymen supervisors and
contractors. This has even greater implications for the non-union
residential workforce in the United States who have no apprentice-
The majority of injuries from pneumatic nail guns involve
puncture wounds to the hand and fingers (Baggs, Cohen, Kalat, &
Silverstein, 1999, 2001; Dement, Lipscomb, Li, Epling, & Desai, 2003;
Lipscomb, Dement, Li, Nolan, & Patterson, 2003; Lipscomb & Jackson,
2007). However, very serious injuries have been documented in the
trauma literature (Beaver & Cheatham, 1999; Jithoo, Govender, &
Nathoo, 2001; Kizer, Boone, Heneveld, & Orozoco, 1995; Takagi, Mori,
Murase, & Hirose, 2003; Wang, Chen, & Tsai, 1999; Webb, Ramsey,
Dignan, & Drinkwater, 2001; Wu, Tham, & Oon, 1975), in the press in
recent years (Associated Press [AP], 1998, 2004, 2005; Broadwater,
2007), and through OSHA investigation. One such investigation (U.S.
Department of Labor, 2007) involved a 26 year-old residential
carpenter who died following an unobserved fall while using a nail
gun. He wasfoundwith a nail of about 3 inches through his brainstem
which resulted in his death. The OSHA investigator concluded that “he
apparently fell with his finger on the trigger.” The safety mechanisms
on the tool were found to be in use and functioning, in this case,
exactly as a contact trigger operates. Had this worker fallen with a nail
gun with a sequential trigger in his handhe would have to have pulled
the trigger after the nose piece contacted his skull to have incurred
4.1. Conclusions and implications for the industry
Documentation of the marked reduction in this traumatic injury of
wood frame construction among union carpenter apprentices is
gratifying. Because the vast majority of residential construction in the
United States is not done by union labor, efforts are needed to expand
this success to others, including those employed in the non-union
sector. These data provide no evidence indicating that concerns about
possible musculoskeletal outcomes should delay action to prevent the
much more common acute traumatic injuries.
A variety of safety professionals could play instrumental roles in
the diffusion and adoption of basic training requirements and use of
tools with sequential actuation systems. For example, the delivery of
training in the non-union sector is particularly challenging since most
carpenters do not go through formal apprenticeship programs. Efforts
to reach individuals involved in technical training programs, at the
high school level and beyond, are indicated as are efforts to develop
effective training or refresher programs that can be used on small
construction sites. Attention is called for to assess effectiveness of
mentored training and ways to improve early training among non-
English speakers as well (O'Connor, Loomis, Runyan, Abboud dal
Santo, & Schulman, 2005).
Use of the safer sequential triggering mechanism should be
mandated, but until such regulation is in place the purchase of nail
guns with the safer actuation mechanism should be encouraged. It is
of note that this is not a new call (le Nobel & Wing, 1987); the patent
for the safer trigger is over 30 years old (Burke, Lemon, & Shippee,
1974). To accomplish this end, outreach is needed to homebuilders
who purchase tools as well as vendors and those who rent tools to
users. Involvement of safety professionals and workers’ compensation
carriers could also be helpful.
Nail gun injuries are common, they can be costly (Lipscomb,
Dement, & Behlman, 2003), and they are potentially very serious. The
risk factors associated with their use are well-established, and feasible
abatement methods have now been demonstrated. The most recent
voluntary industry sponsored ANSI standard (ANSI, 2003) is weak,
calling for shipment of framing nailers with sequential triggers, but
not their use. This has allowed manufacturers to ship a contact trigger
in theboxwiththetoolwiththesequentialtrigger. Althoughthere are
no OSHA regulations calling for use of sequential triggers or minimal
training requirements, the general duty clause could also be invoked
by OSHA compliance officers to call for and enforce both. Such actions
could prevent many injuries and rare, but senseless, deaths associated
with use of this tool.
This work was supported by a cooperative agreement between the
Center to Protect Workers’ Rights and the National Institute for
Occupational Safety and Health (1 U54 OH008307-02). We would like
to acknowledge the Carpenters District Council of Greater St. Louis
and Vicinity, the Home Builders Association of Greater St. Louis and
the Home Builders Association of Southern Illinois for their partner-
ship in this work. We particularly want to thank the instructors at the
CarpentersJoint Apprenticeship Program in St. Louis, Missouri and the
Southern Illinois Carpenters Training Center in Belleville, Illinois for
allowing us into their classrooms and for their enthusiasm for
preventing injuries among their trainees. Lastly we want to thank
the apprentices who provided the data that made the analyses
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Hester Lipscomb is a Professor in the Division of Occupational and Environmental
Medicine at Duke University Medical Center. She is an injury epidemiologist with
expertise in the construction industry.
James Nolan and Dennis Patterson are union carpenters affiliated with the
Carpenters District Council of Greater St. Louis and Vicinity. In addition to over 60
combined years of construction experience, they each have 10 years of occupational
safety research experience. Both are OSHA 500 certified.
John Dement is a Professor in the Division of Occupational and Environmental
Medicine at Duke University Medical Center. He is and epidemiologist as well as a
Certified Industrial Hygienist (CIH).
H.J. Lipscomb et al. / Journal of Safety Research 41 (2010) 241–245