Incident Cause Analysis Method (ICAM) Report BBNA, Inc - Visalia Facility Forklift Incident- August 1, 2012

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Incident Cause Analysis Method (ICAM) Report

Date: August 1, 2012 Time 9:50 a.m.

Site: BBNA, Inc Facility: Visalia, CA

Injury: Minor scrape Potential Injury: Fatality

Investigation Team: Eddie Thompson (Shipping Manager), Anthony Hernandez

(Area Lead), Francisco Carranza Jr. (Injured worker), Gary Hofmann (EHS Manager)

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Incident Cause Analysis Method (ICAM) Report

INCIDENT DESCRIPTION

Employee was instructed to lift a load onto a truck in the dirt area West of

building three. As the employee was heading to location of the load, the

shipping lead yelled to him to use caution while moving towards the

truck/trailer. While the shipping lead was calling to the ee turned and

looked in that direction. While looking to the side and continuing to move

the forklift forks slid underneath a metal bar that was almost completely

buried in the dirt. The bar passed through the forks, next to the mast of

the forklift, thru the spokes of the steering wheel, scrapped the side of the

ee’s neck and took their hard hat off pinning it to the roof of the forklift.

Photos of Incident as a Reenactment

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Metal bar as it is

caught and

picked up by

single fork.

Photos of Incident as a Reenactment (Cont’)

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Metal bar as is

passing next to

mast headed

towards steering

wheel.

Photos of Incident as a Reenactment (Cont’)

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Metal bar has

passed next to

the operators

neck and pinned

hard hat to roof.

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Incident as seen by area

Metal bar as it

had passed next

to the mast,

through the

steering wheel

and removed ee’s

hardhat.

Absent or Failed Defences

• Proper PPE was worn but not effective for impact strike

• Operator failed to stop equipment when being spoken too but rather looked in the direction of area lead

• Workspace was congested with loads and trailers in close proximity to one another

• Distracted driving hazard identified but employee complacent about occurrence

• Site had been “cleaned” and leveled but remaining material not recognized as a hazard

Individual / Team Actions

• Operator failed to stop equipment when being spoken too but rather looked in the direction of area lead

• Distracted driving hazard identified but employee complacent about occurrences

• Employee failed to report previous incidents of distracted driving

Task / Environmental

• Work area believed to be relatively clean

• Sound levels were within “shipping area” levels

• Weather had been excessively hot for some time

• Work environmental was outdoors with adequate lighting

• Workspace was congested with loads and trailers in close proximity to one another

Organisational Factors

• Workspace was congested with loads and trailers in close proximity to one another

• Distracted driving hazard identified but employee complacent about occurrence

• Site had been “cleaned” and leveled but remaining material not recognized as a hazard

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ICAM Analysis Chart

Absent Or

Failed Defenses Individual/ Team Outcomes Task/ Environment

Organizational

Factors

Forklift

Incident

Occurred

Operator failed to stop equipment when being spoken too

Distracted driving hazard identified but

employee complacent

Work area believed clean but unrecognized

hazards remained

Buried hazard not identified

Workspace congested with loads and trailers in close proximity to one another

Employee flailed to report previous incidents of distracted

driving

Workspace congested with loads and trailers in close proximity to

one another

Weather excessively hot

Relatively new employee

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ICAM Conclusions

Root Cause

• Site had been cleaned but remaining buried material not recognized as a hazard

Contributing Factors

• Operator complacent about distracted driving

• Employee had recently been employed

• Workspace was congested with loads and trailers in close proximity to one another

Recommended Corrective Actions

• Removal of “all” material when an area is to be cleaned. (Immediate Done – Eddie Thompson)

• Conduct “Stop for Safety” for all employees involved with mobile equipment (Immediate Done – Area supervisor)

• Emphasis on safety during high production parts essential (On going – All supervision)

• Evaluate employee training and update as necessary (On going - Area supervisors/EHS Manager)

• Evaluate distracted driving reporting incidents as they occur (On going - Area supervisors/EHS Manager)

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Key Learning’s

• If indentified as a risk, take action, fix it!

• Some risks appear harmless but can cause a severe injury under certain circumstances.

• Ensure adequate training and always utilize properly trained personnel.

• Do the job right the first time to avoid future exposure to high risk tasks.