ROOT CAUSES

DISCUSSION

Management Responsibilities

Caddell management failed to implement contractual requirements for responsibility and accountability for contractor safety programs.

Safety Requirements Implementation

Caddell management failed to implement requirements of the medical surveillance program and implement personnel work restrictions; failed to implement safety policy into an effective worker safety program (Job Safety Analysis, fall protection, signs and barricades).

Caddell failed to identify the requirements for a Job Safety Analysis for the temporary platform. As a result, there was a hazard analysis process failure associated with platform use that was not identified, and appropriate safety counter-measures (fall protection, signs and barricades) that were not implemented.

CONTRIBUTING CAUSES

DISCUSSION

Procedures

Procedures in effect at the time of the accident (fall protection, signs and barricades, medical surveillance, Job Safety Analysis) were disregarded. The successful application of these procedures could have prevented the accident.

Oversight

Assessments by ID and LITCO did not reveal the failure of Caddell management to enforce the medical surveillance program and implement work restrictions.

Supervision

The Caddell Project Superintendent failed to implement safety responsibilities for the safety programs. This contributed to deficiencies in worker safety program.

Illumination

The area at the temporary platform had low lighting levels (2 foot-candles) which may have caused visibility problems around the platform.

Platform

The platform was left in place when work was completed, creating an attractive nuisance. Safety measures for such a platform should have included toeboards, guardrails, and support for platform edges or signs and barricades.

Signs and Barricades

The absence of signs and barricades at the elevated edges of the stack contributed to the accident.