Narrative

• A man working alone was painting the fascia

board of a house.
• He erected his ladder at a steep angle with
footing at the edge of the sidewalk. He did not
tie to fasten the ladder.
• He went up the ladder with paint brush and a
gallon of paint on either hand.
• He over stretched his body across the left rail of
the ladder causing it to fall.
 DOMINO THEORY OF ACCIDENTS

PEOPLE, PROPERTY, ETC.

ACCIDENT / INCIDENT
IMMEDIATE CAUSES
LOSS OF CONTROL

BASIC CAUSES

MANAGEMENT ORIGIN (S) SYMPTOMS EVENT TLV LOSS

2
TLV = Threshold Limit Value = exposure day after day without adverse effect.
 DOMINO THEORY OF ACCIDENTS

ERTY, ETC.
ES

C
S

NT

ET
A U

PROP
L

DE
S C
RO

Y,
T S E E
T

RT
U

CI
O N A IA
C C D

PE
AC
O F I C E

E,
S M

O
S S BA M

R
LO I

PEOPL
P
E,
PL
O
PE
MANAGEMENT ORIGIN (S) SYMPTOMS EVENT TLV LOSS
3
 Domino Theory Analysis
LOSS OF BASIC CAUSES IMMEDIATE ACCIDENT LOSS
CONTROL CAUSES
NO SAFE PERSONAL UNSAFE ACTS Fall from height Serious back
OPERATING FACTORS over 4M high injury, LTA
PROCEDURE while doing
(SOP) paint job on a
ladder
OPERATING JOB FACTORS UNSAFE Hospitalization
PROCEDURE CONDITIONS costs
OBSOLETE
UP-TO-DATE Damage to
SOP BUT NOT ladder
FOLLOWED
Spilled 1 gallon
paint
“An unsafe act can result in an unsafe
condition.”
LOSS OF BASIC CAUSES IMMEDIATE CAUSES
CONTROL
NO SAFE PERSONAL UNSAFE ACTS
OPERATING FACTORS 1. Using a ladder without non-slip footing
PROCEDURE 2. Placing ladder at edge of sidewalk
(SOP) 3. Erecting ladder at very steep angle (over 75 deg)
4. Did not get a buddy to hold the ladder
5. Going up ladder holding brush and paint LH & RH
6. Did not tie ladder to the porch rail
7. Man over stretches across left ladder rail and falls
OPERATING JOB FACTORS UNSAFE CONDITIONS
PROCEDURE 1. Ladder footing easily slips
OBSOLETE 2. If ladder footing slips it will fall to the roadway
3. Ladder erected over 70 deg is not stable
4. A ladder with no one holding can easily fall
UP-TO-DATE 5. Poor grip on ladder
SOP BUT NOT 6. Ladder not tied falls to the ground if unbalanced
FOLLOWED 7. When his belt buckle crosses the L rail it falls.
“An unsafe act can result in an unsafe
condition.”
UNSAFE ACTS
1. Using a ladder without non-slip footing
2. Placing ladder at edge of sidewalk
3. Erecting ladder at very steep angle (over 75 degrees from horizontal)
4. Did not get a buddy to hold the ladder
5. Going up ladder holding brush and paint LH & RH
6. Did not tie ladder to the porch rail
7. Man over stretches across left ladder rail starting the fall.

UNSAFE CONDITIONS
1. Ladder without non-slip footing easily slips
2. If ladder footing at edge of sidewalk slips, it will fall to the roadway
3. Ladder erected over 75 degrees grade is not stable
4. A ladder with no one holding can easily fall
5. Holding objects while climbing ladder results in poor grip on ladder
6. Ladder not tied falls to the ground if unbalanced
7. When his belt buckle crosses the L rail the ladder is unbalanced & it falls.
 BASIC CAUSES
PERSONAL FACTORS
1. Lack of awareness / knowledge
2. Lack of awareness / knowledge
3. Poor assessment of stability of ladder
4. Over confidence in ability to be stable
5. Lack of knowledge on proper grip
6. Lack of knowledge on how to fasten L
7. Poor judgement
JOB FACTORS
1. Ladder only has 2 contact points
2. Ladder when used tends to move
3. A tall, thin object tends to fall down
4. Tall objects need to be stabilized
5. Keep a good grip on ladder at heights
6. Hold or fasten ladder to prevent fall
7. Avoid top loading ladder
IMMEDIATE CAUSES
UNSAFE ACTS
1. Using a ladder w/o non-slip footing
2. Placing ladder at edge of sidewalk
3. Erecting ladder at very steep angle
4. Did not get a buddy to hold the ladder
5. Going up ladder holding brush & paint
6. Did not tie ladder to the porch rail
7. Man causes ladder to fall.
UNSAFE CONDITIONS
1. Ladder without footing slips
2. Ladder can fall to the roadway
3. Ladder over 75 degrees grade not stable
4. A ladder not held can easily fall
5. Not holding ladder can cause a fall
6. Ladder not tied falls.
7. Unbalanced ladder easily falls.
 CONTROLS (SOP OR
SPA)
SAFE OPERATING PROCEDURE
1. Pre-work plan
2. Identify steps to do job and hazards
of each step
3. Put appropriate SPA for each hazard
4. Ensure mental/physical /emotional
ability of worker / proper training
5. Ensure ladder specs such as non-
slip footing and rope to tie ladder at
upper level.
6. Ensure barriers around workplace
7. Correct methods such as, always
face ladder, maintain at least 3
point contact, belt-buckle always at
centerline of ladder.
BASIC CAUSES
PERSONAL FACTORS
1. Lack of awareness / knowledge
2. Lack of awareness / knowledge
3. Poor assessment of stability of ladder
4. Over confidence in ability to be stable
5. Lack of knowledge on proper grip
6. Lack of knowledge on how to fasten L
7. Poor judgement
JOB FACTORS
1. Ladder only has 2 contact points
2. Ladder when used tends to move
3. A tall, thin object tends to fall down
4. Tall objects need to be stabilized
5. Keep a good grip on ladder at heights
6. Hold or fasten ladder to prevent fall
7. Avoid top loading ladder.
 Standard Operating Procedure
• Before doing job again ensure the identified
immediate causes are corrected
• Review the training requirement of person,
specs of material, equipment and workplace
• Specify standards for worker, specs for
material, equipment and workplace
• Incorporate the Safe Plan of Action into the
Standard Operating Procedure.