Situation
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.
Changes
- 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.
Right!
To prevent accidents like the one described, it is important to maintain the normal conditions that were identified:
1) The supervisor should be stationed near the doorway to check routine operations. In this case, the supervisor's absence contributed to the accident. If the supervisor had been present, they could have alerted the handcart personnel to the approaching forklift and prevented the collision.
2) All equipment, including forklifts, should have operable headlights. In this case, the inoperative headlight on the forklift made it difficult for the handcart personnel to see the oncoming vehicle. Ensuring that all equipment is in proper working condition, including headlights, would have improved visibility and prevented the accident.
3) Casual conversations should be avoided while operating machinery. The presence of an idle worker engaging in conversation with the forklift driver distracted them from paying attention to their surroundings. It is important to maintain focus and concentration while operating machinery to avoid accidents.
Additionally, improving the following factors would have also helped prevent the accident:
- Proper lighting on the ramp leading to the docks. The low lighting contributed to the handcart personnel's inability to see if there was approaching traffic in the mirror. Installing adequate lighting in this area would have improved visibility.
- Clean mirrors. The presence of dirt on the convex mirror made it difficult for the handcart personnel to see clearly. Regularly cleaning and maintaining the mirrors in the warehouse would have provided a clear view of approaching traffic.
By addressing these changes and maintaining the normal conditions, the accident could have been prevented and the handcart personnel's injury avoided.