| Case Name |
Crash disaster during work by the communication adjustment error. |
| Pictograph |
|
| Date |
January 18, 2001 |
| Place |
The Hyogo ward in the Hyogo Prefect. Kobe City |
| Location |
the penthouse in the building site |
| Overview |
The counter weight of the crane hit the worker who was carrying out work by entering the turning range, and he was thrown as a reaction,and he fell about 10m downward and got injured. This happened because the worker used the prohibited crane without knowing it had been taken out of use as a result of repairing the penthouse in the building site. It is necessary to surely carry out the communication adjustment during work. |
| Incident |
The worker was hit by the counter weight of the crane and knocked off the roof while working on the apartment-house new construction field, and he fell at about 10m, and he got injured.
1 The generation date : Around 10:10 a.m. January 18th
2 The type of the construction : The architecture business ( apartment-house )
3 As a disaster :, the injury
4 The victim : The male
5 The age : 25-year-old
6 The occupation : The mould carpenter
7 The years of experience : 9 years
8 The period in the field : 7 months
9 The type of the disaster : The crane disaster |
| Sequence |
* In the previous arrangment from 11:30 in the previous day,the employee in charge of the crane told that the use of the crane was prohibited from this afternoon, but it would be used from the next day, because it had a problem with the electric system of tower crane and required repair.
* In the evening, the tower crane repairer told that the repair work was late and it would take until the morning of the next day,so he promoted to notify that the use of the crane is prohibited in the greeting of tomorrow morning. The employee in charge of the crane agreed.
* After the morning gathering, gymnastics, KY activity were carried out from 8 a.m. the day the accident occured. That day's precautions of the work, etc. were announced by the main contractor and about 60 workers set about the work simultaneously.The crane use prohibition was not mentioned clearly.
* The mould traders approached the workplace and he carried out the parapet mould assembly work. The victim was carrying out the necessary work for the setup of the separator. He kept working because the work was extended in spite of the break time at 10 o'clock.
* In the case of parapet mould assembly work and welding of the separator around
10:10 a.m. at the most upper floor elevator shaft division, the victim was hit by
the counter weight because of the sudden tower crane circling, and he fell about 10m
downward, and got injured. |
| Cause |
* Since the use prohibition of the crane was not communicated ( the communication adjustment imperfection during work ), different traders who thought the crane can be used operated the crane.
* The worker entered the crane operating radius without any communication.
* The cause that the communication adjustment did not go well
1 Though the charge employee of our company was absent, because of illness, there was no communication on the use prohibition of the crane.
2 Only the employee in charge of the crane consented to the change, and other employees did not know it.
3 On the day of the accident, all the members thought the crane can be used for the previous arrangement as on the previous day .
4 In the morning gathering, it was not clear to all the members about prohibition of using the crane, and the crane repairer did not express his opinion especially either.
5 When the crane repairer was carrying out the repair work, the use prohibition sign was not sufficiently displayed because he intended to do the trial run.
6 There were some other traders who thought they could use the crane, but they gave up using it after looking at the repair situation. They did not communicate with the other traders and the main contractor company.
7 Though the mould traders were also working in the counter- weight turning range, they did not prohibit entering the hazardous area nor monitor the workers sufficiently.
8 As the crane repairer came in for the rest in the morning and he then left the field, it became a condition that the crane can be used by anybody.
9 The crane operator thought there was nobody around there because it was the rest time.Then, he manipulated the crane without looking around well. |
| Countermeasures |
* The previous work arrangments between employees should surely be carried out and there would not be a leakage.
* In the crane erection plan, the separation of the best height of the building is confirmed in the drawing, and the separation of at least 2m is ensured.It is also similarly examined in the time of the climbing.
* The safety equipment of the machine is not canceled.
* Prohibition of entering the hazardous area is surely carried out. ( prohibition of entering the turning range is done thoroughly ) |
| Knowledge Comment |
* It was put in the disaster case sheet, and it was made to be the education material.
* The facility countermeasure ( separation over 2m ) was made to be crane installation criteria of the company. |
| Background |
The most essential thing for the accident prevention countermeasure for the intermingling work of the worker of multindustry type in the same place is the safe traffic control. It is required that mutual employees, the main contractor company and cooperation traders and mutual cooperation traders should communicate and adjust ( the work previous arrangment ) for the traffic control.
In this case the disaster was caused by insufficient mutual communication adjustment between employees who should carry out the traffic control, and it is a typical case of the communication adjustment shortage during work. In the background, humans have the instinct of "carelessness" and "the experience of the danger".It is necessary to surely confirm the safety countermeasure. |
| Account of Concerned Parties |
The victim said "I did not think the crane circled" and " I was lucky not to die".
The assaulter said "I did not think that there was a person present". |
| Reason for Adding to DB |
Not to repeat the same mistakes many times |
| Scenario |
| Primary Scenario
|
Organizational Problems, Inflexible Management Structure, Usage, Operation/Use, Bodily Harm, Harm to Physical Well-being, Bodily Harm, Harm to Physical Well-being, Bodily Harm, Injury
|
|
| Number of Injuries |
1 |
| Consequences |
Since it was settled with the injury this time, the effect was small. If someone had died, the effect seems to come out by being reported in the mass media etc. |
| Multimedia Files |
Fig2.Plan and cross section
|
| Field |
Civil Engineering
|
| Author |
NONAKA, Tadashi (Japan Civil Engineering Contractors' Association)
KUNISHIMA, Masahiko (The University of Tokyo)
|
