| Case Name |
A construction worker fell from a 30 m high roof of the elevator due to his short cut action. |
| Pictograph |
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| Date |
April 25, 2000 |
| Location |
The condominium building construction |
| Overview |
The gouging construction worker lost his balance when taking a leap from the 12th floor toward the roof of long span elevator staying at the 11th floor. As a result, he fell and died from the 12th floor to the first floor. |
| Incident |
After gouging work on the 12th floor of the condominium ended, the victim intended to raise upward the long span elevator from the 11th floor to 12th floor, in order to take down his work instruments. Then, he lost his balance when he leapt to the roof of the elevator (80cm difference in level), and he fell down about 30m from the niche of the perpendicular net on the edge of the roof to the first floor. As a result, he died. |
| Sequence |
On that day, at the condominium construction field, morning gathering, gymnastics, KY activity were carried out from 8 a.m., and following that, precautions of the work, etc. was announced by the main contractor . Then, at last, 40 workers set about the work simultaneously.
In the meantime, the victim (the fourth tier subcontractor) carried out the preliminary arrangement of the work, and they arrived at the field at around 10 a.m. Work on that day was confirmed during operation instruction by the main contractor, and the gouging work was carried out on the 12th floor of the condminium and ended shortly after noon.
Afterwards, the victim carried his work instruments to the front of the stage of a long span elevator stopping at the 12th floor, in order to carry them down.
The long span elevator had been rising up to the 11th floor, then the vicitim asked the worker who had operated the elevator, "Are you going to go up to the 12th floor?", but the operator answered, "It stops at the 11th floor for unloading", and began to unload the burden.
At around 12:35 p.m., the victim thought hat he would raise the long span elevator stopping at the 11th floor up to the 12th floor, and, even though the stairs were 2m away from him, he did not use these stairs, and leapt to the roof of the elevator which was 80cm below the 12th floors uptake stage. But he lost his balance and crashed down from the edge of the perpendicular network to the first floor, and died. |
| Cause |
* It was difficult to carry down 30kg of work instruments to the first floor by hand, so there was no other way tha using the long span elevator.
* Since it was the lunch break time, the victim had to have a meal quickly, in order to go to the next site.
* it was so trouble some for him to go down the stairs that he took a short cut.
* We can suppose that he tried to take a leap to the roof to lift up the long span elevator, because the level difference between the 12th floor and the long span elevator was only 80 cm.
* Spot contractors did not receive the new attendance education.st before the accident.
* Every controctors appointed the person who was in charge of the long elevator, but the workers did not always keep the rule. |
| Countermeasures |
* For spot contractors or others who ente for the irregular time, the new attendance education must be surely carried out.
* For the spot contractors, the previous-day's staff issue the safe instruction by FAX, and they have to confirm the safe indication matter againa on the day.
* The operator of the long span elevator shoud be appointed, and the operation of the elevator must be carried out only by him
* The height of the stage door should be 1.1-1.6 m.
* The yellow card system should be introduced as an unsafe action prevention measure of the worker. |
| Knowledge Comment |
* The human instinct itself causes the disasters such as a short cut action.
* The short cut for work is also the shortcut for life.
* Let's pass through the safe alley way even if it is longer way. |
| Background |
* Since the work was extended to the lunch break, the victim had to have a lunch as soon as possible, because he had to go to the next site in hurry.
* He felt that using normal stair was cumbersome, so he tried to do a short cut.
* The new attendance education was not done for the spot contractors. |
| Incidental Discussion |
The safety equipment and alley way, etc. had been installed, but the victim himself removed the handrail of the elevator, entered the prohibited zone, and tried to take a leap to the roof of the elevator. It is a typical short cut action. However it is very difficult to make this kind of workers be keen to safety issues, even more spot contractors. Site manager are required to provide enough safety equipment, and the safety and health education and guidance in order to eliminate such disasters and improve the morale of the workers. |
| Scenario |
| Primary Scenario
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Carelessness, Insufficient Understanding, Ignorance of Procedure, Disregard of Procedure, Poor Value Perception, Poor Safety Awareness, Organizational Problems, Poor Management, Non-Regular Movement, Movement During Transition, Malicious Act, Rule Violation, Bodily Harm, Death, Loss to Organization, Social Loss
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| Number of Deaths |
1 |
| Field |
Civil Engineering
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| Author |
KUNISHIMA, Masahiko (The University of Tokyo)
BABA, Kanji (ICHITEC CORPORATION)
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