Fall Between Barges (KV89v2)


What Happened?

On March 22, 2013,  an employee went to assist another employee in securing two barges with ropes. The employee stated there was poor lighting and everyone was in a hurry to finish work since it was Friday. The employee misjudged the distance of and fell between the two barges head first. He received serious injuries to his left leg and right shoulder. The crew was able to extract the employee from between the two barges.

Contributing Factors

Because of self-imposed Time Pressure they did not take the time install proper lighting before beginning work.  

What Can We Learn?


The employee could have used a Self-Check (Stop, Think, Act, Review) to focus on the task at hand instead of trying to finish fast.

A Peer Check could have made him consider the distance between the barges.


Time Pressure was present as the employee told officials he was in a hurry to get home.

The crew fell into the Physical Environment trap by working without proper lighting.  

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?