| Case Name |
In the one person work, a tractor shovel fell from slope. |
| Pictograph |
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| Location |
The site of road remedial work. |
| Overview |
Using a tractor shovel, a worker did an unscheduled job by himself on about a 24-degree slope which was the limit of its performance in terms of gradability and stability, and the tractor shovel turned over on its side.
Immediately the victim was taken by ambulance to hospital , and he died from a basal skull fracture.
The causes are as follows:
( i ) The machine was operated on about a 24-degree slope which was nearly the limit of the performance of the tractor shovel.
( ii ) The worker drove the tractor shovel which was not in the schedule of the day.
( iii ) The site manager did not carry out the accurate instruction, and left the site. |
| Incident |
One of 2 workers drove the hydraulic backhoe and did excavation and leveling of the slope where stumps had already been removed. The other was scheduled to watch downward passage which was designated as a school zone. But he drove the tractor shovel without an induction man, and climbing on the slope, the tractor shovel fell from the slope, he suffered injuries, and died. |
| Sequence |
During the morning, the site manager and 2 workers did the work of removing the root of the stump on the slope on the upper part of the road. In the daytime, since the site manager returned to the company, 2 workers started the work by each judgment from the afternoon. The driver of hydraulic backhoe did excavation and leveling of the slope where stumps had been already removed. The other was scheduled to watch a downward passage which was designated as a school zone.
Since the figure of the worker who watched the road was not seen, the driver of the hydraulic backhoe got out of the hydraulic backhoe and looked at about a 24-degree slope downward. He discovered that the tractor shovel was on its side. The victim was taken by ambulance to hospital, and he died of the brain contusion by basal skull fracture. |
| Cause |
Using the tractor shovel, a worker did a work on about a 24-degree slope which was the limit of its performance in terms of gradability and stability
Not scheduled, without the workmanship instruction in the site, the worker drove the tractor shovel only by his own judgment, and climbed the slope without an induction man.
The site manager did not carry out the accurate instruction, and left the site.
The engine key of the tractor shovel had been used by taking it out from the box behind the seat, therefore anyone could easily use it. |
| Response |
Immediately, the victim was taken by ambulance to hospital. |
| Countermeasures |
1. The preparation of work planning.
In work planning, the next matter must be described.
* Type and ability of using car-type construction equipment.
* Operation route of car-type construction equipment.
* The method of the work of car-type construction equipment.
2. The selection of appropriate car-type construction equipment.
3. The arrangement of an induction man.
4. Appropriate storage and management of engines keys of car-type construction equipment and the like.
5. The accurate workmanship instruction of the person in charge.
6. The execution of the safety education.
7. The review of the safety management system. |
| Knowledge Comment |
1. One person work and unscheduled work are origins of accidents.
2. Car-type construction equipment is operated according to work planning.
3. The work which exceeds the performance of the machine is impossible. |
| Background |
1. The negotiation with the inhabitant of the work zone was delayed, and it was impossible to remove the decay earth and sand on the road before the work.
2. There was no indication from the field person in charge, and as a result, the work was started by the worker's judgment .
3. It was the one person work. |
| Scenario |
| Primary Scenario
|
Carelessness, Insufficient Understanding, Ignorance of Procedure, Disregard of Procedure, Insufficient Analysis or Research, Insufficient Prior Research, Poor Value Perception, Poor Safety Awareness, Organizational Problems, Poor Management, Organizational Problems, Poor Management, Usage, Operation/Use, Regular Movement, Dangerous Movement, Malicious Act, Rule Violation, Failure, Large-Scale Damage, Bodily Harm, Death
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| Number of Deaths |
1 |
| Physical Damage |
a tractor shovel. |
| Field |
Civil Engineering
|
| Author |
IKAI, Seiji (ICHITEC CORPORATION)
BABA, Kanji (ICHITEC CORPORATION)
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