This is the accident scenario:

• An employee is working on a ladder and the ladder seems to collapse.The employee falls off the ladder and breaks arm.

The investigation reveals the following details:

• Employee had worked seven 12-hour shifts in a row.
• Accident happened at end of shift.
• Employee was standing on the top step of the ladder (an unsafe action).
• The employee was approximately 10 feet above floor level.
• A ladder inspection policy is in place, but there is no evidence that the ladder has ever been inspected.
• Investigation reveals the ladder was damaged and did not provide a stable working platform in any environment.
• Interview with facility manager reveals that he did not inspect the ladder when it was due for inspection. He was aware that ladder needed to be inspected.

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Factors and Possible Causes Affecting Incident

• Extended work hours may have caused employee to be tired and not clear-headed.
• Employee violated safety rule (standing on top step). 
• Ladder was defective and unusable.
• Ladder had not been inspected.
• Facility manager was aware that ladder needed to be inspected but did not adhere to the existing policies and procedures for ladder inspections.

What is the Root Cause?

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.

What about the Other Factors?

• Extended work hours might contribute, but there is no statistical evidence available that indicates extended work hours increase the risk of accidents.
• The safety rule violation could be a contributory cause in this accident, but not the root cause. However, if the ladder had been used properly, it is possible that the incident might have been prevented.
• The existence of a fall arrest system may have prevented or reduced injury. This could be a contributory cause.
• The fact that the ladder was defective is certainly a contributory cause. But if the facility manager had followed procedures and removed the ladder from service, the accident would have been prevented.

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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.