23.4.

2023
Fatal incident case study-1
Dear safety professionals,

Recently I came across an incident in a factory premises wherein in the third shift at
3.30a.m., a fatal incident occurred to a transport vehicle driver. The driver had just
parked the heavily loaded truck near the unloading dock. He got down to open the
rear door and then wanted to go back to driving seat and reverse fully and park at
right place on dock wall for easy unloading. When he opened the reverse door, the
loaded truck (without hand brake and a wheel choke) on a slopy road condition,
moved back and the driver, before he could do anything to save himself, got crushed
between his own truck rear side and the nearby pillar.
What went wrong?

1. Why did the driver not apply handbrakes?

A – He was not applied handbrakes because according to the incident brief, it seems
that there was no safe system implemented that is why no supervision or monitoring
there. If System was there, then driver not gone to open the rear door by self.

2. Why were the wheel chokes not put in place?

A – Most of the drivers do not have much education. So, due to lack of awareness
and overconfidence if there is no supervision or enforcement by the system to do so.
Then they think, it is a waste of time.

3. Why was there no any support person (cleaner) or guard to help the driver for
reversing safely?
A – Small transporter not providing support / cleaning staff to their vehicle driver due
to cost saving or some time due to the less contract value. It has also reflect there
was no safe system implemented.

4. Why did the dock material logistics team not available to see the incident and help
the driver to save life? Do these kinds of mishaps usually occur at shift change,
lunch breaks, tea breaks where most people leave the workplace but few do not?
A – No, because most of system oriented company or workplace have the proper
system for material In / Out with strict timing. Another thing may be is improper
contract management. Now a days , where no system , companies given whole sole
contract to the transporter and after that they are not think about anything because
the mind-set of the company’s employees is to not to take the responsibility after
given the contract. This is the reason, nobody came or available there to help them
or save them.
5. Was the illumination in the third shift enough to see clearly the area?
A – 3:30 PM is the daytime, so I do not think illumination was an issue there.

6. Was a it a fate/ God’s will for the driver to end his life this way?
A – No, it’s purely safety lapses.

7. If you were the Factory safety officer, what would be the preventive actions would
you take? a. in all dock areas, b. guidance to all transport companies/ suppliers, c.
Dock safety checklist improvements, d. odd time safety inspections.
A - b. guidance to all transport companies/ suppliers

8. If you were the Factory inspector, how do you utilise this incident to initiate
preventive actions across all industries in the state?
A – Through the Incident Investigation, point out the root cause and identify the gaps
/ lapses and advised to the management where and how improvement required
avoiding the repetition.

9. If you were the insurance company head, how do you look at this?
A – According to company policy & insured terms, first they has to investigate the
root cause and collect the legal documents i.e. FIR Company, Medical report, Post-
mortem, Statement of witness, decrease legal documents i.e. Aadhar , PAN, Bank
Statement, Nominee documents etc. from insured company. Also, check the
negligence due to the accident.

10. If you were the Factory Manager, occupier, what would be your response?
A – First inform to the company authorities and administrative bodies i.e. Local police
station and take to the IP to the nearest hospital. If medical officer declared dead,
then inform to the labour Inspector, Factory inspector, Insurance Company and
theirs family. After communication gather all the documents i.e. workplace & legal.

11. If you are the RTO inspector general, what would you do with this learning?
A – RTO inspector responsibility to create awareness amongst the local drivers as
well as provided guidelines to the local companies to adopt safe systems in the view
of vehicle movement and use within premises.

12. f you are a third party auditor for ISO 45001, what will you do for your clients?
A – As a third party auditor for ISO 45001, advised client to adopt safe and secure
system and regular system audit.

13. If you are a common man, what precautions would you take?
A – As a common man, always need to check the system for human being safety is
there or not. If there , how it work and what & how he need to follow.

14. If you run a motor driving school, what would you do?
15. If you were the head of security and administration of this factory, what would
you do?
16. If you were head of Supplier Capability Building who organises supplier safety
and ESG audits, what would you do?
17. In your career if you have come across similar incident and have learnt the
lessons closely, pl. do share the incident.
18. What can be the engineering controls in this area?
19. Can this happen in your factory, warehouse also?
20. What do you intend to do to prevent such incidents in your workplaces?

Pl do study this case in groups of senior people drawn from cross functions and then
respond before 28th April 2023 on grp1402@gmail.com
Use pictures, clip art, diagrams, wherever possible. The best responses will be
recognised suitably.
regards,
Govind Pitre,
ESG practitioner,
9922419763