Change or Difference

Analysis

Planned/Normal

Present

Difference

Analysis

Fall protection procedure requires 100 percent tie-offs and anchorage past six feet from edge.

Fall protection procedure disregarded by Project Engineer.

Fall protection harness was not used by Project Engineer.

Failure to follow fall procedures contributed to fatality.

Signs and barricades procedure requires obstructions to deter the passage of personnel and signs warning of hazards at required locations.

Signs and barricades procedures disregarded by Caddell/Air-Con, Inc., personnel when they left the platform in place.

Barriers and warning signs not in place near platform and edge of boxes to warn personnel.

Compliance with this procedure may have prevented fatal accident.

Personnel are able to maintain normal balance and imbalance recovery.

Project Engineer was unable to recover balance.

Project Engineer's diabetic neuropathy may have impaired his ability to maintain or recover his balance.

Project Engineer had impaired sensory functions in lower extremities possibly due to diabetic neuropathy.

Project Engineer's characteristic behavior was role model of safety consciousness.

Personnel are able to judge hazardous work conditions and avoid them or wear protective equipment.

Project Engineer walked without hesitation and without fall protection into a clearly dangerous situation. He also failed to use access and radiological control protocol.

Project Engineer may not have been able to judge hazards present near platform.

Uncharacteristic behavior for this Project Engineer.

Project Engineer approached to within 6 feet of the elevated edge and stepped onto platform without fall protection.

Being unaware of hypoglycemic condition may be a factor in this situation since this condition may alter judgment, balance, and vision.

Potential hypoglycemic condition may have impaired judgment. In addition, because of advanced diabetic condition, the Project Engineer may have lost the ability to detect the onset of hypoglycemic events.

Temporary platforms required to have fall protection provided along with warning signs and barriers.

Job Safety Analysis and/or Construction Safe Work Permit required for each work package.

Air-Con, Inc. personnel had 100 percent fall protection when platform was in use. Static lines, warning signs, and barriers were removed, but platform was left in place.

Job Safety Analysis and/or Construction Safe Work Permit not performed for temporary platform .

Air-Con, Inc., temporary platform was left in place following completion of specific items of work with no warning signs and barriers.

Platform hazards were not identified, safety provisions for platform not provided.

Unsafe conditions at platform resulted in Project Engineer fatal fall.

Failure to identify hazards and provide safety measures contributed to the accident.

Temporary lighting by Air-Con, Inc., for work activities at platform.

Temporary lighting was not provided for Project Engineer and Crane Vendor drive wheel inspections.

Project Engineer may not have had sufficient lighting to identify the hazards associated with platform.

Lighting may have contributed to the accident.

Medical surveillance program must provide for identification of fitness for duty issues and enforce work restrictions.

Caddell medical surveillance program identified Project Engineer general health conditions and work restrictions.

Project Engineer work restrictions were not enforced.

Deficiencies in medical surveillance and failure to enforce work restrictions contributed to the accident.

Subcontractor management must accept accountability and responsibility for subtier safety.

Caddell management failed to execute contractual requirements for the safety program.

Caddell did not implement requirements of worker safety program.

Caddell management's failure to implement contractual safety requirements contributed to the accident.

Progressively severe penalties for violation of safety requirements should provide rapid response to corrections.

LITCO steps up severity of penalties as Caddell fails to respond to contractual requirements.

Caddell fails to enforce requirements in worker safety program.

Led to gradual improvements in worker safety program, but failed to prevent recurring imminent danger situations.