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TheCaseoftheWobblyLadder:AnAccidentInvestigationCaseStudy

SafetyCultureToolkit

InjuriesandIllness
Wednesday,January2nd,2013

Everyoneistalkingaboutsafetyculture.Thisfree
toolkitwillhelpyouimproveyourexistingprogram,
orstartoneatyourcompany.

Itisoftenhelpfultoseeanexampleofanaccidentinvestigationinordertobetterunderstandhowtheprocessworks.
Hereisasimpleaccidentinvestigationcasestudy.

byckilbourne

Thisistheaccidentscenario:
Connectwithus
Anemployeeisworkingonaladderandtheladderseemsto
collapse.Theemployeefallsofftheladderandbreaksarm.
Theinvestigationrevealsthefollowingdetails:
Employeehadworkedseven12hourshiftsinarow.
Accidenthappenedatendofshift.
Employeewasstandingonthetopstepoftheladder(anunsafe
action).
Theemployeewasapproximately10feetabovefloorlevel.
Nofallarrestorrestraintsystemwasused.
Aladderinspectionpolicyisinplace,butthereisnoevidencethat
theladderhaseverbeeninspected.
Investigationrevealstheladderwasdamagedanddidnotprovidea
stableworkingplatforminanyenvironment.
Interviewwithfacilitymanagerrevealsthathedidnotinspecttheladderwhenitwasdueforinspection.Hewas
awarethatladderneededtobeinspected.

FactorsandPossibleCausesAffectingIncident
Extendedworkhoursmayhavecausedemployeetobetiredandnotclearheaded.
Employeeviolatedsafetyrule(standingontopstep).
Nofallarrestsysteminplace(requiredat6feetabovefloorlevel).
Ladderwasdefectiveandunusable.
Ladderhadnotbeeninspected.
Facilitymanagerwasawarethatladderneededtobeinspectedbutdidnotadheretotheexistingpoliciesand
proceduresforladderinspections.

WhatistheRootCause?
Whichfactor,ifnotpresent,couldhavepreventedtheaccident?
Ifthefacilitymanagerhadinspectedtheladderanddiscoveredthedefect,theladderwouldnothavebeenused,and
thisaccidentwouldhavebeenprevented.
Failuretofollowestablishedladderinspectionproceduresistherootcause.

WhatabouttheOtherFactors?
Extendedworkhoursmightcontribute,butthereisnostatisticalevidenceavailablethatindicatesextended
workhoursincreasetheriskofaccidents.
Thesafetyruleviolationcouldbeacontributorycauseinthisaccident,butnottherootcause.However,ifthe
ladderhadbeenusedproperly,itispossiblethattheincidentmighthavebeenprevented.
Theexistenceofafallarrestsystemmayhavepreventedorreducedinjury.Thiscouldbeacontributorycause.
Thefactthattheladderwasdefectiveiscertainlyacontributorycause.Butifthefacilitymanagerhadfollowed
proceduresandremovedtheladderfromservice,theaccidentwouldhavebeenprevented.
Therootcauseofthisaccidentcouldevenbetrackeddeeperthanjustfindingthefacilitymanagersfailuretoinspect
theladder.Withmoreindepthanalysis,itmightbefoundthattherealcausewasafailureinthesystemitself.Perhaps
thesafetysysteminplacehadnomeansofensuringthefacilitymanageractuallycarriedouttheseinspections.
Itisforreasonslikethisthataccidentinvestigationsarebestconductedbyateam.Thiscanensurethatasmany
possibilitiesareexploreduntilallcausesarediscovered.Itiseasytoplaceblameonindividualswheninactuality,the
problemmaybewithyourmanagementsystems.
SHARETHIS
ARTICLE

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11/22/2016

TheCaseoftheWobblyLadder:AnAccidentInvestigationCaseStudyEHSDailyAdvisor

Tags:accidentinvestigationaccidentscenariocasestudyinspectionladderinspection

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