A Tragic Lesson

A Tragic Lesson

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.

Read the complete article and see the incident photgraphs here: http://www.healthandsafetytips.co.uk/Articles/A_Tragic_Lesson.htm