Case Ditails

Scenario
Case Name A worker fell from a height of 3.5m during the work of pulling up the pail can onto the stage for taking loads.
Pictograph
Date September 25, 2002
Place Akiruno City, Tokyo
Location Outside scaffold at the construction of home nursing support center
Overview During he was pulling up the mortar in the pail can to the stage by the tiger rope by himself, he fell and died.
Incident At about 11:45 a.m. on the 25th September 2002, during the independent work of pulling up the mortar in the pail can to the stage by the tiger rope, the pail can was going to fall, and the worker tried to catch it, and he hung out of the clearance between the handrail and the middle rail, and then he fell.
At 13:15 on the day of the accident, the victim was confirmed to have died of tension pneumothorax at the hospital he was taken to.
Sequence * At 7:30, 4 persons including the victim (plasterer) arrived at the field.
* At 7:50, Safety meeting was carried out. (KY activity was done.)
* The victim was instructed to repair the handrail of the veranda of the second floor and the base board of the first floor from the chief.
* At 10 o'clock, the workers took a rest.
* At 10:30, they started working again.
* At 11:30, the tile construction worker who was working at about 10m away heard a loud thump. (The victim fell.)
* At 11:38, the ambulance was called.
Cause * The victim worked without careful consideration.
* He was instructed that he should use the stairs for pulling up the load, but he did the work by the rope.
* He did not use the safety belt.
* He was working with an unstable posture.
* The usage of the stage for taking loads had not been clarified.
* The instructions on the use of the stage for taking loads were insufficient.
* There was no equipment (the winch elevator) for discharging the loads.
* There were no instructions on the operational procedure.
* The instructions on the use of the safety belt were insufficient.
Response * The stairs were added beside the stage for taking loads since the similar work would continue.
* The winch was installed.
Countermeasures * The equipment for discharging the loads should be installed in place.
* The lifting method for every material should be clarified, and the operational procedure should be developed.
* In the safety meeting, the instructions should be given very carefully.
* The work of discharging the loads with using rope is to be forbidden.
* The instruction on the use of the safety belt should be done thoroughly.
Knowledge Comment * Do not underestimate the work on light duty.
* For the new workers, the attention should be paid in the first week.
* The dependent work needs caution needed.
* Regard all the people who work in the same field as your brothers.
Background * The victim worked as a plasterer with his father who was the business owner after he graduated the junior high school. He was a veteran with the experience of 22 years, but it seems that he did not have enough skill to become independent.
* The alley way for carrying the mortar was about 60cm and it was inconvenient to go up and down.
* Though the contractor was about to install the elevator for the construction in the scaffold plan and the lifting plan which were made before the construction, he installed the stage for taking loads causing this accident and lifted the load by transportable crane according to the result of examining the running cost.
* Since the building was low and the number of heavy loads was not so large, the elevator was not installed.
* It was the first day of entering the field.
* The meeting report of this group says "In the work of lifting loads, a lifting and lowering device is used."
Sequel The victim was the only one son of the owner, and the mother and the sister were greatly depressed in those days. After the accident, the owner closed his business. As an administrative penalty for this accident, infraction of Occupational Safety and Health Act was not accepted, and the contractor and the subcontractor received the following "instruction sheet."
1) To develop the operational standard which does not include the necessity for the work of lifting loads in high places, and to communicate it to the appropriate workers.
2) To take measures such as founding an outside staircase which makes it easy for the workers who are carrying materials and instruments to move to the workplace.
3) To take measures such as installing equipment for lifting loads at the edge of the work floor in order not to carry out the work of taking loads when there is a danger of falling.
4) To take measures to prevent falling such as using safety belts in the case that the work of lifting loads in high places is necessary.
5) To give the instruction to the new workers which reflects the situation of the field and achieves results.
All the workers were interviewed by a police investigator since the Labor Standards Supervision Office expressed the opinion that it was suspicious that there was no one who witnessed the accident and only the thump was heard even though 40 people were working in the same building. (Suicide might be also considered.) The cause of the falling is just a speculation. When the accident was actually reconstructed, it turned out that the work should have needed improperly strong power, and it is just thought that the worker should have used the stairs.
Incidental Discussion The words of the chief of the Labor Standards Supervision Office were impressive, which were "I cannot figure out why no one witnessed the accident in spite that there were so many people in the field. The victim could not be made turn in his grave. Therefore I investigated this case thoroughly."
Account of Concerned Parties The author also interviewed the about 40 workers, and most of them said that "I wonder why he fell from such a place."
Reason for Adding to DB The reason is that the intensive recognition is gained that accident would occur even if any kinds of safety devices are installed and there is any direct correlation between the safety level of the devices and the human behavior.
Scenario
Primary Scenario Ignorance of Procedure, Disregard of Procedure, Carelessness, Insufficient Precaution, Organizational Problems, Poor Management, Regular Movement, Dangerous Movement, Bodily Harm, Death
Number of Deaths 1
Field Civil Engineering
Author NONAKA, Tadashi (Japan Civil Engineering Contractors' Association)
Scenario