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Fatal Accident Review and Recommendations
We will review a fatal accident that involved a “Concrete Company” responsible for operating the pump and ensuring proper pouring of the concrete and a “Concrete Pump Company” in charge for bringing the concrete in a truck, and also drive and operate it at the work-site.
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The accident occurred in a new residential area underdevelopment. They were pouring concrete for the walkways of houses under construction in the neighbourhood. The day the accident occurred, the concrete pump was at a residential worksite and prepared to pour the concrete to make walkways. The concrete pump operator pumped the concrete, the job almost completed. The worker noticed that concrete had stopped coming out of the end hose, he immediately switched the emergency stop button to halt the pump. At that moment, concrete exploded from the end hose of the concrete pump truck. The concrete worker was holding the end hose to pour the concrete into the forms. The violent eruption of concrete from the end hose forced the concrete worker backwards. The force of the impact made him fall backwards, the heel of his boot got jammed on a piece of lumber and the back of his head landed on a scrap piece of wood, resulting in a fatal head injury.
As a result, our team was assigned to investigate, analyze and provide recommendations to change practices, processes and/or policies that should be implemented by the company to eliminate or mitigate the risk of reoccurrence. Our recommendations are:
- New Safe Working Practices
- Enhanced Equipment Controls
- Workers’ training and experiences
- Communication between workers
- Safety Headgear (PPE)
- Introduction Workplace Housekeeping Checklist
Below I will define the implementation of the “Enhanced Equipment Controls” recommendation.
The main components of equipment controls are: the identification of equipment hazard in the workplace and eliminating or reducing the risk of those hazards causing harm.
The first step in prevention is consulting both the workers and workplace health and safety representatives. This will give employees an opportunity to provide input and raise potential safety concerns about the work they do. Management can gain valuable insight on the exposed hazards and improve their understanding of how employees do their job. Afterwards, a walk-through survey will be completed, and the compilation of both reports will consequently optimize the hazard findings.
Several types of hazards were identified relating to the equipment safety, the simple action of moving parts has enough force in motion to cause serious injuries to workers. For example, machinery can be reached by workers, machinery can eject, machinery can reach workers and equipment can be accessed by workers. In this accident, the hazards identified relating to the equipment were: blockage of the hose, length of the hose, proper setting of the equipment, poor maintenance of the equipment and non-regulated parts – attachment at the end of the hose. Subsequently, several equipment control interventions will be required, such as: the access to the machinery, the inspection of the equipment, the required maintenance, repair, installation and cleaning of the equipment.
Employees must be provided with a safe access to perform their work around machinery and equipment. A stable work platform allows good posture and sure footing to prevent falls. Employees performing their work tasks must be provided means to get to the equipment and use with the equipment with minimal to no risk of falling or getting injured. Access needs to be planned and predicted in advance. Our health & safety team will inspect work-sites before sending employees on site to ensure they are safe. If they are unsafe, we will be following up on the recommendations.
In order for inspections to be impactful, the information must be analyzed and put in practice. The health and safety committee will be designated to take responsibility for analyzing the situation and determining what actions are required.
The committee will require training since analyzing inspection reports is an important task. At least two to three employees will be responsible for reviewing the inspection reports and they will have the control over the necessary corrective measures. If during an inspection, there are some concerns raised that have some immediate danger, these concerns will be reported to the management team and corrective actions will be taken rapidly.
Finally, information obtained from these inspections will require a complete analysis in order to determine which areas need corrective measures, and to identify weaknesses as part of the audit program. Diligent and complete reports has the potential to accomplish the following:
- Identify the need for training; clarify why certain types of accidents occur in certain areas;
- Determine the order of priority for corrective action;
- Help establish best practice work methods or improve certain existing methods;
- Identify equipment, tasks, for which an in-depth risk analysis may be required.
To finish, employees also need access to machinery and equipment in the workplace for expected tasks such as operation, maintenance, repair, installation, service or cleaning. Access to the equipment will be made available to employees according to their roles and responsibilities. Going forward, accesses will be controlled and only permitted to employees that have the authority.
New standards for the Concrete Pumps industry (CSA-Z151) were established in 2009 to reduce the amount of accidents in the trade. As a result, the enforcement of inspections on various parts is regulated and must performed by qualified workers. They must be performed daily, monthly and yearly on parts that are subject to wear and tear.
A prevention program includes numerous types of inspection. Below are all the different types of inspections which will be put in place;
Spot inspections are completed in order to meet the employers’ responsibilities with respect to work place health and safety. They focus on speciﬁc industry specific hazards for example, the hose being teared or damaged.
Critical parts inspections are regular inspections of certain parts of a machine which have a great potential for serious or even deadly accidents. This type of inspections is usually part of a preventive maintenance or hazard control program. For example, newly acquired equipment involve checking all mechanisms that are used before the new piece of equipment is sent on a work-site. This means that prior to operating a recently acquired pump, the installer would check to ensure that all the parts correspond to the manufacturing specifications and are correctly functioning.
Routine inspections are inspections carried out regularly, they cover all the regular maintenances and have documented practices in place.
Going forward, these inspections will be performed by a machine operator and recorded accordingly to provide proof of completion. All details of the various inspection, maintenance, modifications, etc. are to be kept in a log, in a chronological sequence. Details such as who performed the work and how many hours were on the machine at each service are to be kept in the log. As part of the inspection, the machinery employee would ensure that no modification to the equipment was in place and that all settings of the equipment are standard with the manufacturer.
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In order for the team to be most effective in their work they will require a good knowledge and understanding of processes, tasks and operations. In addition, they will benefit having the knowledge of the hazards associated with the equipment and machines. Having the staff made aware of previous accidents will also help them be sensitive to the importance of the work they are doing.
Management will ensure the employees (health & safety committee and machinery operator personnel) have the knowledge and training required to conduct effectively their work. They will also monitor the logs to ensure proper documentation and ensure proactive actions are taken.
The manufacturers provide a maintenance schedule which defines the run hours and it serves as a general guideline given the large amount of variables machinery might be subject to, such as weather and ambient temperature conditions, material differences of concrete mix design and the load it is subject to, i.e. light, medium or heavy-duty. The health and safety department in collaboration with the mechanical department will therefore, develop a preventative maintenance program that specifically suits the needs depending on the usage of the equipment. The inspection reports will also assist in developing some maintenance requirements specific to how the equipment is utilized.
All repairs, installation and cleaning of the equipment will be outsourced to a reputable external vendor that has the knowledge and expertise in; concrete placing systems, pump supplies, cleanout accessories, shotcrete accessories, metric hydraulic hoses & fittings and concrete admixtures.
The company’s desired results are to protect their employees from the dangers of a whipping hose accident. The tools supplied make a worker’s job much easier because the hoses themselves can be dangerous if handled and maintained improperly. The hoses derive power from the liquid that moves inside them; however, that power also creates a volatile force. If the force is strong enough, it can cause the hose to whip, possibly causing serious injury if it strikes a worker. Proper equipment controls are not only the affair of the Concrete Pump Company but also the workers as they access and use the equipment on the worksite. In addition to all the regular inspection, maintenance and cleaning of the equipment the following must be respected by all workers on the work-site;
- Prior to using the hoses, be on the lookout for tears or damages.
- Access and use the equipment correctly by reducing the pressure in the hose to a lower level if possible, as this can minimize the possibility of the hose whipping.
- Avoid making sharp bends in the hose, which can damage the reinforcement.
- Avoid jerking the hose as this can cause ruptures.
- Ensure fittings are fully secured, never connect or disconnect pressurized hoses, always depressurize them first.
Providing the workers with knowledge of the importance of equipment control and the hazards it can create, in addition to all the equipment control measures in place will dramatically minimize the risks of all workers on the work-site.
The implementation and timelines will be prioritized and have the main objective to eliminate hazards entirely if possible, but if that can’t be done, the implementation schedule will focus to minimize the hazards. It will take a period of two years to implement the program in its entirety. We will start with the substitution of any equipment that is not recommended by the manufacturer. All the equipment will be inspected, and non-manufactured parts will be replaced over the next six months. All parts identified to be replaced with a large cost must be approved by the finance team to ensure proper budget and funding.
The immediate hire of two experienced machine operators to enable the required inspections, followed by engineering controls, which includes the development of personalized maintenance schedules to be developed by the machinery team and management over the next six months. They will be gradually rolled-out over the next year to ensure all the equipment follow the new specification to ensure proper maintenance, repairs and cleaning.
The new administrative control will guarantee that all employees are trained over the next month to ensure they properly utilize the equipment so that they can reduce risks they have on the job-site. The two additional health and safety personnel in the next 6 months will focus on visiting and monitoring work-sites to ensure workers are respecting the different controls. To conclude, HR & the marketing team will create banners in the cafeterias and locker rooms announcing all our new initiatives and site safety notices will be posted on work-sites. In the first year, we will also create a quarterly award for the teams that have no reported accidents. A lunch will be served with management and a huge banner the team can hang on their truck or work-site claiming that they are the winners, this will be prepared by HR in hand with management. All these measures in sponsorship with management supporting them will reduce the risks of a hose blockage and as a result minimize the risks of “hose whipping”.
Management will monitor the inspections through the log records which will produce accurate data and allow for proper next steps. The health & safety committee and HR will monitor all the training and ensure employees’ completion within the proper timeframe. Health & safety representatives will also go on work-sites to monitor and observe the way workers are utilizing the equipment. Also, a review of all accidents and working habits of all the sites inspected by the health & safety team will occur monthly and it will serve two purposes: to nominate the “health & safety” winning team for that month and review of all the accidents to determine if any common accidents, that would require further prevention. Finally, financial key performance indicators will be designed by the finance team to enable the firm to periodically check on the performance of the business to ensure it is functioning in compliance with the budget.
The company will benefit from an improved competitive advantage, as it will maintain an efficient operation, and this efficiency will provide them a competitive advantage. This also means more investment in better equipment, and increased productivity from employees. The ability to purchase better equipment due to improved profits, the business will purchase more efficient and updated equipment.
The new “Equipment Control Approach” will reduce major repair costs while lowering maintenance costs. Also, the new equipment will require less maintenance therefore, spending less money on repairing on old equipment that breaks down.
The direct and indirect impacts on employees include better direction, and guidelines and objectives on how well they need to perform their jobs. This will create a culture of safety conducts and a mindset for caring for the equipment. Increase pay for employees as better profits allows company more flexibility to increase wages for employees. Employee morale will increase since employees will focuse on specific objectives and they will see the results of their efforts in their paychecks. With improved morale, employees will enjoy coming to work and this will result in lower turnover. With a lower turnover rate, the employees that are trained continue to execute as per the standards, know the equipment and have good working experience, this diminishes accidents and breakage of equipment due to improper usage. The firm will be able to hire better employees as it can afford to pay higher wages therefore, attracting better employees.
Lastly, the firm with all these measures will eliminate the amount of severe accidents and reduce the amount of minor accidents. Subsequently, the workers’ compensation rates will be lower, lowering the risks of fines and legal suits, benefit from an efficient and productive reputation on the market which will result in generating more funds from the multiple partnerships in the industry therefore; injecting additional profits to the company.
In conclusion, people are the company’s greatest asset. The proactive investment in health and safety will demonstrate this belief, while lowering the number of fatalities, injuries, and illnesses in our workplace. It will boost the bottom line through savings in workers’ compensation costs and significant enhancement in productivity. The investment will also improve the financial performance. In addition, the company will promote the health and safety initiatives as the companies’ competitive advantage.
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