Monday Accident & Lessons Learned: Worker drowns in sump; what is in a “good” work plan?
Read the Investigation Report published by here Work Safe Alberta:
1. While replacing a sump pump, an experienced work dropped the assembly parts into a sump (pictured below) that was filling continuously with water.
2. In an effort to retrieve the parts that could not be reached within arms length, the worker fall into the sump getting his head and upper body stuck.
3. Workers once finding him in that condition were unable to remove the jammed worker (suction most likely an issue) and had to call rescue.
4. The worker was pronounced dead at the scene.
Findings and Actions from the Report:
7.1 Direct Cause
7.1.1 Worker 1 got stuck head first in the sump and drowned while trying to retrieve a check valve and a rubber hose adapter that had fallen into the sump.
7.2 Contributing Factors
7.2.1 Worker 1 got stuck in the narrow opening of the sump housing.
7.2.2 Worker 1 was unable to safely retrieve the check valve and rubber hose adapter by hand.
7.2.3 At the time of the investigation, water was continually draining into the sump. The depth of the water in the sump was approximately 76.2 centimeters.
8.2.3 GSS conducted a hazard assessment for sump pump work, developed a “Safe Work Practice for Repair/Replacement” of sump pumps and provided a copy to Occupational Health and Safety. GSS trained all affected workers in the safe work practice.
8.2.4 GSS complied with all orders issued by Occupational Health and Safety.
So if you were reviewing this report, what should the new Work Plan have included?
… one issue not identified is not blocking the sump access area to prevent assembly parts from being dropped in.
If this were a TapRooT® investigation we would start with a SnapCharT® (a sequence of events) and then look for the missing best practices that were related to the Causal Factors by using the Root Cause Tree®. These missing best practices would be the foundations of an adequate Work Plan.