Question

Accident Description:

• Employee is working on a ladder and the ladder seems to collapse.
• The employee falls off the ladder and breaks arm.

The Investigation Reveals the Following Details:

• Employee had worked seven 12-hour shifts in a row.
• Accident happened at end of shift.
• Employee was standing on the top step of the ladder (an unsafe action).
• The employee was approximately 10 feet above floor level.
• No fall arrest or restraint system was used.
• A ladder inspection policy is in place, but there is no evidence that the ladder has ever been inspected.
• Investigation reveals the ladder was damaged and did not provide a stable working platform in any environment.
• Interview with Facilities Manager reveals he did not inspect the ladder when it was due. He was aware that ladder needed to be inspected.

Questions:

1. What are the factors and possible causes affecting the incident?
2. What is the root cause? (Which factor, if not present, could have prevented the accident?)
3. What about the other factors?

Answer 1

1. Factors that might be possible for accident.

(i) Bad scheduling that resulted in fatigue in employee, whose agility might have been impacted due to this.

(ii) Lack of employee training in safe working practices.

(iii) Absence of a fall control or arrest system, which could have lessened the impact of the fall.

(iv) The equipment was damaged and was not nspected or corrected.

(v) The guidelines / procedure for maintenance of equipment was not adhered to.

2. The adherenace to policies and procedures ( which included periodic inspection and scheduling processes) could have prevented the accident.

3. Other factors like absence of protective equipment and employee training contributed to the accident. Thee protective measures could have prevented the accident, though the root cause was non- adherance to the procedures.