Case Ditails

Scenario
Case Name A worker was trapped between a rotating hydraulic backhoe and a chimney.
Pictograph
Location Cable piping work site of refuse incinerator.
Overview In a construction site of refuse incinerator, a worker was caught between a chimney and an hydraulic backhoe during the transportation of formwork members, and he died. The causes were that an induction man was not stationed, that there was no "do not enter" sign on display to the dangerous zone, and that the safety education was insufficient, etc..
Incident The victim had woodchip which was put by the chimney and he was asked to bring it, and he intended to return to the excavation site by passing by the truck and between the chimney and the hydraulic backhoe. But, then the hydraulic backhoe was rotating and was about to load the bored earth and sand, when he was trapped between the rear right side of the upper part of the hydraulic backhoe after rotating and the chimney.
The victim had crouched, holding the woodchip.
The victim was taken to the hospital, and he died from a ruptured spleen, multiple fractures, and spinal fracture.
Sequence The victim participated in morning gathering, tool box meeting, and crisis prediction activity of the original contractor, which started from 8:15 with 3 colleagues. Then the foreman of the original contractor carried out the indication of the content of the work and the attention to the danger of contact with construction equipment.
Afterwards, the victim moved to the workplace on foot with his fellow formworker, and the grading of the position that had been drilled on the previous day and the preparation of formwork of the manhole was carried out.
The operator of the dump truck and the operator of hydraulic backhoe loaded about 1.5m3 of sand in the temporary storage yard for sand which was different from the workplace, and transported the sand to the workplace where the victim was.
The foreman of the company was late to the field, and moved to a different site, after he indicated the content of the work for the day and gave advice about work in the narrow place.
The operator of the hydraulic backhoe put 6 cups of sand for cable protection in the excavation position, and the victim did work of averaging it using a long-handled bamboo winnow.
Afterwards, the operator of the hydraulic backhoe took 15 bags of cement which were a hindrance to rotating
to a direction of the safe alley way and moved the bags so as not to be a hindrance.
The victim was asked to take the woodchip used for the formwork by the formworker who was engaged in
the construction work of the manhole, therefore he took the woodchip, passing through the alley way
designated for the work.
In this interval, the hydraulic backhoe operator had continued to do the excavation, because no one was not
in the excavation position.
The victim had woodchip which was put by the chimney and was asked to bring it, and he intended to return
to the excavation site by passing by the truck and between the chimney and the hydraulic backhoe. But, then
a hydraulic backhoe was rotated and was about to load the bored earth and sand, when he was caught
between the rear right side of the upper part of the rotating hydraulic backhoe and the chimney.
Meanwhile, the operator of the hydraulic backhoe thought that the hydraulic backhoe had made contact
with the chimney, because the sound of "Gari" was made from the rotating hydraulic backhoe.
And after rotating in the opposite direction, he got out of the backhoe, moved around to the chimney side,
and confirmed that the victim had crouched, holding the woodchip.
The victim was carried in the hospital, and died from a ruptured spleen, multiple fracture, and spinal fracture.
Cause The prohibition measures of the entrance to the dangerous zone were not taken in operation range of car-type construction equipment. And, an induction man was not arranged.
The safe indication was not thorough enough.
1. The concrete indication of no entry zone in the workplace was not enough.
2. The stop induction signal, etc. that decided what to do when the construction equipment entered in the no entry zone had not been made.
3. The indication of confirming backward had not been made to the operator of the hydraulic backhoe. By piling cement bags in a safe alley way, it was difficult to be utilized as an alley way. Safety education such as dangerous forecast training (KYT) was insufficient.
4. It was a dangerous action to approach a hydraulic backhoe which was operating, and not to utilize the safe alley way though it was hard to pass through it, and the safety education for the employee was insufficient.
5. KYT activity had been done, and the indication training on "the danger the place" had been done. But the
training which made the workers think about measures of "danger" avoidance was insufficient.
Response The victim was taken to in the hospital.
Countermeasures About the operation range of car-type construction equipment, the measures of entrance prohibition is thoroughly done, and the measures of entrance prohibition is thoroughly communicated to all worker.
The safety education on prevention of contact with construction equipment is done thoroughly.
1. The no entry zone in the workplace is made clear.
2. The method of communication and signal in the case of entering in the no entry zone is determined, and it is thoroughly done.
3. The explanation about installation of the barrier, display of the entrance prohibition, and arrangement of the induction man is repeatedly and thoroughly done in morning gatherings, etc..
4. The safe alley way is secured and the order to pass there is enforced all out.
5. The safety education such as the dangerous forecast activity is done thoroughly, and the training that makes the worker consider even the method of the avoidance measures of the danger is done.
6. Work planning is made, and the operational procedure is determined, and the work is carried out in
accordance with this.
Knowledge Comment The thorough education which makes workers recognize danger as danger and the training which makes workers consider the avoidance measures of the danger are necessary for accident prevention.
Background The tool box meeting is becoming a mere formality, and the instructions and precautions of the foreman of the original contractor and the company don't reflect the actions of the workers.
And, people who guide and supervise can't teach the details and don't grasp the degree of the worker's understanding.
From a shortage of the education for the worker, the sensitivity to danger is little.
Scenario
Primary Scenario Carelessness, Insufficient Understanding, Misjudgment, Misjudgment of Situation, Poor Response to Change in Environment, Change in Environment, Poor Value Perception, Poor Safety Awareness, Organizational Problems, Poor Management, Regular Movement, Careless Movement, Malicious Act, Ethics Violation, Bodily Harm, Death, Loss to Organization, Social Loss
Number of Deaths 1
Field Civil Engineering
Author IKAI, Seiji (ICHITEC CORPORATION)
BABA, Kanji (ICHITEC CORPORATION)
Scenario