Head Injury (KV 174)


What Happened?

A temporary employee working for the day in a printing facility was tasked with retrieving several sets of magnetic printing mats for an upcoming job. The mats were in a separate warehouse from the one housing the printing machines and were magnetically attached to large metal sheets lining the walls. One set of printing mats was located approximately 8 feet up the wall and the employee could not reach them. He noticed a pallet of 5 gallon ink buckets near by and used one of them as a stepping stool so he could reach the printing mats. While reaching for the mats he tipped the 5 gallon bucket over and fell against a metal beam causing him to hit his head. The impact cut his head open and required the employee to go to the hospital and receive 10 staples in his head.

Contributing Factors

The employee did not use the correct tool for the job by standing on an ink bucket instead of retrieving a ladder.

What Can We Learn?


The employee should have used his Questioning Attitude to properly evaluate the hazard and consider the potential risk of falling.      


The employee demonstrated Overconfidence by not considering the potential risks associated with using the wrong tool for the job.  

Vague Guidance played a part in this accident when the temporary employee was not told specifically how to properly complete the task.  

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?