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Case Studies

for
for the
the

ENGINEERING
SECTOR
Prepared on 26 October 2006

Please note that all cases are shared for learning purposes
only and in no way implies any liabilities on any parties.

WSHAC Workplace Safety & Health Advisory Committee


© 2006 WSHAC
2

Case Study 6

Fall From Height

WSHAC Workplace Safety & Health Advisory Committee


© 2006 WSHAC
3

Brief Description
Steel plate involved

Date Oct 2002

Work Process Workers trying to remove a steel


plate from the ground
Casualty One death

WSHAC Workplace Safety & Health Advisory Committee


© 2006 WSHAC
4

Synopsis
 A machine that two co-workers were trying
to service was barricaded with a guard. In
order to remove the guard, one worker
operated an overhead gantry crane to shift
it.
 After shifting the guard, the workers saw an
opening in the metal grating between the
machine and the guard.

WSHAC Workplace Safety & Health Advisory Committee


© 2006 WSHAC
5

Synopsis
 Therefore, the workers proceeded to search
for a cover for this opening and saw a steel
plate lying on the ground.
 The workers proceeded to lift the plate.
 While they were lifting the steel plate and
almost flipping the steel plate over, one of
the workers fell into the opening below the
steel plate.
 The worker was sent to the hospital but
subsequently succumbed to his injuries.

WSHAC Workplace Safety & Health Advisory Committee


© 2006 WSHAC
6

Observations and Findings


 The dimensions of the
opening was 0.88m x
0.88m.
 There were two other
openings in the grounds
Opening and both were also
viewed from
1st floor covered but with different
designs.
 The accident occurred
because the workers did
Where not know that there was
deceased
landed
an opening below the
steel plate.

WSHAC Workplace Safety & Health Advisory Committee


© 2006 WSHAC
7

Root Cause Analysis

Evaluation of loss Fatal


Type of contact Fall to lower level
Immediate Unsafe Act
cause(s)
Basic causes Poor judgement
Failure of SMS Inadequate safe work
practices

WSHAC Workplace Safety & Health Advisory Committee


© 2006 WSHAC
8

Corrective Measures
 Paint warnings on top of the covers to warn
persons against removing the steel plates.
 Better design of steel covers to prevent
similar accidents.

WSHAC Workplace Safety & Health Advisory Committee


© 2006 WSHAC
9

THE END

WSHAC Workplace Safety & Health Advisory Committee


© 2006 WSHAC

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