HSE ALERT

Bulletin # 72866 Completed By Sandeep Patil

Incident Date: 09-06-2020 Approved By Derek Dixon
Incident Classification
☒Injury/Illness ☐ Environmental ☐Vehicle Accident ☐Property/Equipment Damage ☐Near Hit/ Miss
☐Security: Please Specify (__________________) ☐Other: Please Specify ( __________________)

Preliminary Details of Incident

Employee fell down a ladder, approximately 1.5m (5 feet), when descending from the top of an oven.
The IP was investigating a fault with the oven burner, that is located on top of the oven. The IP used an aluminum ladder
to access the top of the oven. When descending the ladder, approximately halfway down, the IP’s right foot slipped
causing them to fall to the ground. The IP suffered a minor injury to their right leg and right-hand ring finger.

What Went Wrong?

The ladder was incorrectly positioned at an
unsuitable angle.
The ladder was not correctly footed. A joining gap in
the concrete floor slabs was used to help stop the
ladder slipping.

Immediate Cause(s)- Figure 1 - Ladder tied at top Figure 2 - Ladder angle & footing
Improper use of equipment (ladder)

Immediate Actions-
First aid was given to IP
Safe use of ladders toolbox was conducted with relevant employees

Lessons Learned-
Process should be established for:

- training people in the safe use of ladders

- choosing the right ladders for the job (length and strength);
- identifying each ladder so that you can keep track of it;
- routine, recorded inspections of ladders and a procedure for withdrawing unsafe
ladders from use;
- secure storage away from sources of accidental damage;
- providing adequate supervision by competent people.

For work at height is tasks:

- identify all types of work where work at height is required;

- assess whether the work can be done without the need to work at height;
- identify if other safer means of access can be used such as tower scaffolds; or
powered access such as a cherry picker or a scissor lift;
- identify the remaining work for which ladders can still be used. Restrict this to
short-duration, light-duty work based on a suitable assessment of the risks. Figure 3 Ladder showing correct 1 in 4
angle (means of securing

HSMSF-050.005 Rev. 01 Form Revision Date: 10-Dec-2019 Page 1