Change Analysis


The regular night shift personnel at the warehouse were loading a truck backed up to the loading dock. A large convex mirror was placed high in the warehouse doorway to allow handcart personnel to see traffic approaching outside on the dock while still inside. The supervisor, who usually stood near the doorway checking the routine operation, was at the west end of the dock. A forklift with an inoperative headlight was approaching the doorway from the east end of the dock. An idle worker was riding behind the driver on the forklift and talking to him.

A helper with a heavy load on his handcart was going down a ramp with a slight incline through the warehouse doorway to the dock. He saw that the supervisor was not present and looked in the mirror, but because of the low light level and dirt on the mirror he could not see if there was approaching traffic. He looked into the dock and could not see any headlight glow from a forklift he thought was on the dock. He yelled for clearance from a man seated in a nearby truck but could not make himself heard due to a loud radio and noise from the idling truck engine. As he went down the incline onto the dock, the forklift loomed into sight at his left. His momentum carried him into the path of the forklift, where he was hit and seriously injured.

Write up a change analysis on the mishap described below. Change analysis will include the following:
1)Identify 3 changes which contributed to the accident.
2)Identify conditions which normally exist.
3)Analyze the mishap and state what could have prevented it.

This is an interesting assignment. I see several changes which contributed to the accident. Please tell us what you see contributed to it and what could have prevented it. We'll be glad to critique your answer.

Accident situation - a hand cart personnel was hit and seriously injured.

- The supervisor who normally stands near the doorway was at the west end of the dock.

- The forklift had an inoperative headlight.

- An idle worker distracted the forklift driver with conversation.

- Dirty mirror and low lighting

Normal conditons
- convex mirror placed in warehouse doorway for handcart personnel to see traffic approaching outside while still inside.

- A supervisor is posted near the doorway to check routine operations.

- Headlights operable on all equipment.

- No casual conversation while operating machinery.

- Proper lighting on ramp leading to docks.

- Clean mirrors.

This mishap could have been prevented if everything stated in the normal conditions was adhered to.


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