This is the accident scenario:
The investigation reveals the following details:
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Which factor, if not present, could have prevented the accident?
If the facility manager had inspected the ladder and discovered the defect, the ladder would not have been used, and this accident would have been prevented.
Failure to follow established ladder inspection procedures is the root cause.
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The root cause of this accident could even be tracked deeper than just finding the facility manager's failure to inspect the ladder. With more in-depth analysis, it might be found that the real cause was a failure in the system itself. Perhaps the safety system in place had no means of ensuring the facility manager actually carried out these inspections.
It is for reasons like this that accident investigations are best conducted by a team. This can ensure that as many possibilities are explored until all causes are discovered. It is easy to place blame on individuals when in actuality, the problem may be with your management systems.
Tomorrow, we'll talk more about accident investigations and offer suggestions about developing an accident investigation kit, containing the items investigators need to do their job.
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