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What happened?
Two workers were preparing to enter a confined space on top of an emergency response water truck.
After conducting a hazard/mitigation assessment, the workers positioned and secured an access ladder.
The first worker ascended the ladder and entered the tank.
The second worker ascended and, during the transition from the ladder to the top of the tank, fell.
Emergency response was initiated by other workers.
The fallen worker sustained serious injuries and was transported to the nearest hospital.
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Why did it happen?
The ladder used was designed for emergency response and had metal footings, rather than safety footings.
The equipment was positioned at ~55 degrees, more than the 4.1 ratio required by regulations for maximum stability.
Crew were focused on confined space entry. This may have overshadowed discussions of other (e.g. ladder-related) hazards.
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What did they learn?
Ensure correct ladders are available for non-emergency tasks.
Before work starts, conduct hazard analysis for emergency response maintenance tasks and implement mitigation plans.
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Ask yourself or your crew
Why do you think the crew:
- used an emergency response ladder?
- positioned the ladder inadequately?
How can something like this happen here? How can you prevent it?
How do you ensure the risk assessment is adequate?
Should an emergency arise, what is your role? Who do you contact? How?
What good practices do we have in place to prevent this? How can we improve?
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What happened?
Two workers were preparing to enter a confined space on top of an emergency response water truck.
After conducting a hazard/mitigation assessment, the workers positioned and secured an access ladder.
The first worker ascended the ladder and entered the tank.
The second worker ascended and, during the transition from the ladder to the top of the tank, fell.
Emergency response was initiated by other workers.
The fallen worker sustained serious injuries and was transported to the nearest hospital.
Why did it happen?
The ladder used was designed for emergency response and had metal footings, rather than safety footings.
The equipment was positioned at ~55 degrees, more than the 4.1 ratio required by regulations for maximum stability.
Crew were focused on confined space entry. This may have overshadowed discussions of other (e.g. ladder-related) hazards.
What did they learn?
Ensure correct ladders are available for non-emergency tasks.
Before work starts, conduct hazard analysis for emergency response maintenance tasks and implement mitigation plans.
Ask yourself or your crew
Why do you think the crew:
- used an emergency response ladder?
- positioned the ladder inadequately?
How can something like this happen here? How can you prevent it?
How do you ensure the risk assessment is adequate?
Should an emergency arise, what is your role? Who do you contact? How?
What good practices do we have in place to prevent this? How can we improve?
Two workers were entering a confined space, accessible through a ladder. One of the workers fell during the transition from the ladder to the top of the tank. He sustained serious injuries and was transported to the nearest hospital for advanced care.
