Two employees who had worked together for many years were working on a simple task to repair a leak in the ceiling. One of the employees was working from a ladder, using a crimping tool that weighed approximately 19 pounds and a tape measure. During the task, the employee switched tools multiple times causing him to lose his focus and balance. While preparing to put down his tape measure and pick up the crimping tool, which was resting on the ladder, the employee fell to the ground. In the process the crimping tool tipped off the ladder causing it to strike the worker in the face as he laid on the ground. As a result, the employee was immediately knocked unconscious, later fell into a coma, and died due to the extent of his head injuries.
2 Minute Drill not performed. If it was used they would have asked what is the best body positioning for the task? Do you have the correct PPE, tools, and instructions?
What Can We Learn?
A Self Check would have allowed the worker to take a moment prior to beginning the task to determine the best strategy for safely completing the job.
A Peer Check would caused the second worker to notice the potential for error and stop the action before an accident occurred.
Although there was an increase chance for error due to the risky manner in which the employee was working, Overconfidence did not allow either of the employees to mitigate the hazards.
Although the task appeared to be simple and the employee was capable of using both of the tools he selected for the job, the employee was Multi-Tasking which caused him to lose his balance and fall.
Ask the Right Questions