Case Ditails

Scenario
Case Name A worker slipped and fell when he peeled protective cover sheet off a roof.
Pictograph
Location Construction site of building a wooden 2-story house .
Overview A plasterer removed personally a handrail for fall prevention, and did not restore the handrail. When he continued the work as it was, he slipped and fell from the penthouse. He did not wear the safety belt either.
Incident When a plasterer A ( 59-year-old ) peeled protective cover sheet(blue sheet) off the penthouse after adding a final coating to the plaster work of the external wall, he slipped and fell over the outside scaffold (middle crosspiece of handrail for fall prevention).
The victim removed personally the handrail for fall prevention of the outside scaffold in order to install the hose of transferring mortar, and he continued the work, as he did not restore the handrail.
* A meeting was not held before the work and during the work.
* A boss of the secondary subcontract carried out arrangements for the workers and the work allocation of the day.
* On that day, the manager was absent, and the instruction by a site manager of the original contractor, who was the responsible for the compound work, had not been done.
Sequence * At 8:30, plasterers A and B were instructed about the work for the day from the boss of the plasterer store of the secondary subcontract .
* The boss confirmed the work of the previous day, and left the site before 9 o'clock.
* From 9 o'clock, plasterers A and B started final coating plasterer work around the first floor in the same way as the previous day.
* During the morning, the work around the first floor ended, and after they covered the penthouse with the protective cover sheet, they started their lunch break at 12 o'clock.
* From 1 p.m., plasterers A and B started the final coating plasterer work around the second floor.
* Before 4 p.m., the final coating plaster around the second floor ended and they started peeling off the protective cover sheet.
* Around 4 p.m., plasterer A slipped, and fell over the handrail for prevention of tumbling of the outside scaffold to the ground.
Cause 1. The plasterer did not wear the safety belt.
2. The protection sheet was slippery because the plaster chip adhered to it.
3. The handrail for fall prevention was removed, and the work was advanced even though the handrail was not restored.
4. A safety meeting was not held before the work and during the work.
5. There was no consideration about old people doing high-place work.
6. There were no safety measures at the position where the handrail was removed.
7. Safety education and guidance were not kept.
8. There was no operational procedure book.
Countermeasures 1. The handrail of outside scaffold and work floor which has been removed for the reason of work must be restored by the person who removed them and it is his responsibility.
2. Safety measures ( entrance prohibition, handrail stopper and rope, etc. ) in the case of making the dangerous place in the outside scaffold are taken thoroughly.
3. Safety education and guidance are done thoroughly to even workers of the lowest level.
Knowledge Comment Equipment for safety which has been removed for the reason of work must be restored after the work.
Background * The consciousness for working safely was low.
* The protective cover sheet which was slippery had been always used in work.
* Everyday safety education and guidance were not done thoroughly to even the workers of the lowest level.
Scenario
Primary Scenario Carelessness, Insufficient Understanding, Ignorance of Procedure, Disregard of Procedure, Ignorance of Procedure, Disregard of Procedure, Poor Value Perception, Poor Safety Awareness, Organizational Problems, Poor Management, Regular Movement, Dangerous Movement, Malicious Act, Rule Violation, Malicious Act, Rule Violation, Bodily Harm, Injury, Loss to Organization, Social Loss
Number of Injuries 1
Field Civil Engineering
Author IKAI, Seiji (ICHITEC CORPORATION)
BABA, Kanji (ICHITEC CORPORATION)
Scenario