a tragic lesson

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Published on 8 January 2006

This article has been created from an incident report sent to us here at HSfB where a visitor to the site thought it could perhaps help prevent similar tragic events from happening in the future.

Incident Description

At 10.25 a.m. on 11 November, 2005 a plater fell to his death whilst replacing stair treads on the Clipper PW platform. The fall was not witnessed.

Outcome

The Injured Party sustained severe head injuries from which he died.

Main Findings from Investigation

• The Injured Party died as a result of falling through an opening in the stair tower created when two stair treads were removed.
• The team found all the associated permitry to be in place for the work being carried out. The work was prescribed to be undertaken on a ‘one stair tread out, one stair tread in’ basis.
• For whatever reason the Injured Party, in a change to the permitted work method, chose to remove a second tread. This change created a large opening through which he subsequently fell.
• The primary cause of death was the result of a severe head injury caused by a fall from height.

Immediate Causes

The Injured Party died as a result of falling through an opening in a stair tower created when two stair treads were removed.

Immediate Actions

Conduct a risk assessment to cover the specific case of stair tread replacement on the Clipper in order to clear the intent of the Prohibition Notice served by the Health and Safety Executive on 12 November 2005.

Contributory Factors

• The work permit stated that the work should be undertaken on a ‘one stair tread out, one stair tread in’ basis.
• For reasons that can never be established, a second stair tread was removed in a change to the permitted work method.
• This change was never subject to further risk assessment which might have identified additional controls.

Initial Lessons Learned

Senior management actions to address underlying causes:

• With the agreement of the deceased’s family, use the circumstances surrounding this incident to reinforce the message that, if there is a change to an agreed method of work, a reassessment of the work controls must be undertaken.
• The message should also reinforce that in instances where absence of this practice is observed, supervisors and line managers should invoke Just Culture procedures.
• Permit system Custodian to review and amend as required the drop down screens for Hazard Description and Specific Controls to ensure suitability for single person working and inclusion of changes to Working at Height Regulations.
• For all tasks a technical discussion of ‘how’ (tools, processes, methods etc) should be held. Consider recording this, and the parties to the discussion, on the permit as part of the Task Description or by utilising the Head of Department facility within the permit system. 

The opening created when two stair treads are removed

The opening seen from above showing the intermediate landing in the stair tower on which the Injured Party was found.