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KELSAFE '94 Root Cause Analysis Workshop, Case Study #2 Crane Incident Disclosure Number: IPCOM000217215D
Publication Date: 2012-May-04
Document File: 31 page(s) / 3M

Publishing Venue

The Prior Art Database

This text was extracted from a PDF file.
This is the abbreviated version, containing approximately 32% of the total text.

Page 01 of 31



Root Cause Analysis

Subject: Workshop #1 -



Workshop #2 -


Classroom type arrangement with two large dry ink boards and overhead projector.


The intent of the session is as follows:

0 Demonstrate root cause analysis via actual example

0 Demonstrate the benefits of using the process

0 Outline when to use it Demonstration:

Issued selected witness statements from the actual incident and coached through the process by workshop leaders.


0 Explanation of intent and participant selection
- 10 mins.

0 Root cause analysis demonstration 50 mins.

0 Actual results

- 10 mins.

0 Questions

- 5 mins.


Document package from actual study

Page 02 of 31


The craftsmanwas alightingfrom a portabletoilet facility onsitewhen an American, 9310 Crawler Crane, working to the North of the toilet area overturned. The crane boomwas being lowered by-thecrane operator, over the side of the machine. The boom length was 200 feet, fly jib was 40 feet. The crane operator stoppedthe lowering of the boom when the boomwas at an angle of approximately25" because, one track of the machine had lifted off the ground.

The sudden stoppingof the boomexacerbatedthe problem and the cranesubsequently overturned.

The crane boom came down on top of the portable chemical toilet that the craftsman was coming out of. The toilet collapsed and the toilet door struck the craftsman in the back causing him to fall to the ground.

It is notfully understoodat which point the craftsman sustainedthe compressionfracture to T/12 - Ll (Falling to the ground or impact from the toilet door).

Investigationof the cause of the incident is in progress and afull report will besubmitted on completion.

This injury was not reportedon the day of the incident due to the fact, the fracture being so small, was only confirmed by a medical practitioner today, Friday November 3rd, 1993.

Duration of lost time expected is approximately three weeks.

Total manhours achieved up until the time of the accident stand at 9,571,597.



- Subject: Lost Time Injury



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Page 03 of 31


Responsiblefor first aid treatment and fire protection.

At approximately 10:15 hours, the medicaldepartment received a emergency call via radio.

approximately 2-3minutes.

-- 0 Two other employees responded via ambulance to Module 4, east end on roadway 18, took approximately 3-5minutes due to traffic.

On arrival a male employee was lying on his back on a port-o-can door.

0 We were informed that the employee was exiting theportscan at the time the crane overturned. An extensive search of the area revealed no other injured employees.

0 The injured employee was conscious, coherent and able to describe the painto the middle of his back and right hip area.

0 No external bleeding was noted or internal bleeding suspected.

0 No obvious fractures present.

0 Employee answered questions with clarity indicating no loss of cons...