Case Ditails

Scenario
Case Name The carpenter who was guiding the suspension load ( the roof boards ) of the crane tipped a balance and fell.
Pictograph
Date May 2, 1998
Place The Yonago City, Tottori Prefecture.
Location 2-floor wooden building new construction field.
Overview The carpenter(C) was laying the roof boards at the 2-floor wooden building new construction field. When he was about to guide the roof boards hung on the crane to the temporary place on the second floor beam ( the 5m height ), the suspension load ( the thirty roof boards which were ( length ) 1800 millimeter X ( width ) 900 millimeter X ( thickness ) 9 millimeters ) was moved by the gust ( about 6m/s wind velocities ). Though he intended to hold the suspension load, he tipped a balance, and fell 2.5m on the first floor.
Incident Around 9:30 a.m. May second, 1998, in the 2-floor wooden building new construction field, the thirty roof boards 30 hung on the crane were moved by the gust, and the carpenter (C) fell on the first floor, and got the three months' serious wound.
Sequence * Each woker gathered at 8 o'clock in the morning, and started to prepare each work.
* Since the operation chief of the assembly of the wooden building(A) ( the engineering firm president ) had other work in another place, the supervision of the work had been left to the carpenter (B).
* Since all the workers were trained, only by crarifying sharing of roles, the work was started under the supervision of carpenter (B) from 8:30.
* Since rainy weather would be anticipated from next day, it changed to the operational procedure in which spread of the second floor roof board and installation of the sheet for the rain curing finished during the day in the judgment of carpenter (B).
* Since rainy weather was anticipated from the next day, the carpenter (B) changed the schedule. The new schedule consisted of finishing laying the roof boards on the second floor and installing the sheets for the rain curing.
* Around 9:30 on the beam, when the carpenter(C) was guiding the roof boards hung on the crane to the temporary place, the roof boards were moved by the gust.
* Though he intended to hold the suspension load, he tipped a balance, and fell 2.5m on the first floor.
Cause * Though the operation chief (A) ( the engineering firm president ) did not clearly give responsibility and authority to the carpenter (B) ( who did not have the qualification of the operation chief ), (A) made (B) control the work.
* Though the bad weather was anticipated, the carpenter(B) proceeded the work without preparing the method to prevent falling from the beam.
* Carpenter (C) carried out the work on the roof beam without using main rope and safety belt.
* Carpenter (C) intended to hold roof boards which were moved by the gust.
Countermeasures * The operation chief of assembly of the wooden building(A) ( the engineering firm president ) or the person who has qualification of the representative operation chief is stationed in the erection work field, and he carries out direct work control and supervision.
* The crane work during the gusts should be forbidden.
* To forbid the work on roofs and beams without installing the prevention of falling.
* To use the safety belt on roofs and beams.
* To prepare the main ropes and the level nets at every field.
Knowledge Comment * In the document, it is formulated that the operation chief involved in the erection work is permanently stationed and carries out the direct control and supervision , and it is known to the party to everybody.
* The standard of stopping works in the significant meteorology is clarified, it is formulated and known to the party to everybody.
* The rule which forbids the work when there are no handrails and main ropes, and the level nets, is instituted.
Background * Since the president of the engineering firm suddenly had to work in another area, it was not possible to control the work in the field.
* Since there were consecutive holidays from the next day and weather forecast said it would rain, the operational procedure was changed on the judgment of the carpenter (B).
* The safety consciousness of the manager of the engineering firm and the main contractor company was poor, and the leadership was also insufficient.
* The workers (the carpenters) did not sufficiently recognize the danger of the work without using the safety belt and the previous staff meeting also lacked.
Sequel * In the next construction, the operation chief directed the workers to use the safety belt on the roofs and beams before the work started by the oral in the meeting.
* In the engineering firm, the construction responsible person of the main contractor company completed to prepare the necessary quantity of main ropes and level nes in all fields.
Incidental Discussion * The engineering firm president and the main contractor company thought the productivity (the efficiency ) and the cost reduction more importnat than the safety countermeasure in high-place work.
* The similar disaster had been occurred one year before, and the main contractor company directed to use the main ropes and safety belts on roofs and beamswork.
Account of Concerned Parties * Though the carpenter (C) had no habit to tighten the jaw strap of the protection cap everyday, he did not be warned.
* The carpenter (C) did not have the safety belt. He did not realize the necessity of using it in the high-place work either.And, he did not be warned by the president of the engineering firm.
* Since carpenter (B) signaled to the crane on second layer of the outside scaffold, he did not notice the possibility of the gust.
Reason for Adding to DB For the same or similar labor accident not to happen again.
Scenario
Primary Scenario Organizational Problems, Inflexible Management Structure, Organizational Problems, Poor Staff, Organizational Problems, Inflexible Management Structure, Poor Value Perception, Poor Safety Awareness, Poor Response to Change in Environment, Change in Environment, Non-Regular Movement, Movement During Transition, Non-Regular Movement, Movement During Transition, Bodily Harm, Harm to Physical Well-being, Bodily Harm, Injury
Sources The construction industry labor accident prevention association publication "daily comprehensible safety management in the low rise residential building field" ( the safety and health education text for the boss who is a foreman )( from case No.1 promotion method of CS-1disaster case study 2002.3 publication ) .
Number of Deaths 0
Number of Injuries 1
Physical Damage Especially, it is lacking.
Financial Cost The indistinctness.
Economic Loss The indistinctness.
Consequences The labor accidents in the construction field of the low rise residence not only cause the social distrust for the responsibility of the main contractor and the engineering firm but also inclease the anxiety and the distrust of the clients, neighborhood inhabitants and observers.
Field Civil Engineering
Author KANO, Koji (Japan Construction Safety and Health Association)
KUNISHIMA, Masahiko (The University of Tokyo)
Scenario