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Fatal Fall Incident: Preventative Measures and Best Practices for Industrial Safety

This incident report highlights a tragic event in a cement operation where a contract welder fell to his death while cleaning a kiln. The root cause was management neglecting proper risk assessment and safety procedures. Best practices include SLAM approach, hazard recognition training, restricting access to openings, and using barricades or warning signs for safety. Promote a culture of safety to prevent such tragedies in the future.

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Fatal Fall Incident: Preventative Measures and Best Practices for Industrial Safety

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  1. MNM Fatal 2006-19 • Fall of Person • August 21, 2006 (California) • Cement Operation • Contract Welder • 37 years old • 15 years experience

  2. Overview The victim, was fatally injured when he stepped on a manhole located at the bottom of a kiln and fell approximately 28 feet to the concrete below. The victim and a co- worker were cleaning a section of the kiln that was being replaced.

  3. Root Cause • Management failed to conduct an assessment of the risk involved before assigning personnel to perform tasks inside the kiln. Safe work procedures were not initiated to ensure that persons were protected from hazards of open manholes inside the kiln. No barricades or warning signs were posted at all approaches where safety hazards were not immediately obvious to employees.

  4. Best Practices • Stop, Look, Analyze, and Manage, SLAM each task to identify all potential hazards. Initiate action to protect yourself when performing every task. • Train all miners to recognize hazards from falling and ensure that safe work procedures are discussed and established. • Restrict access to covers over openings that were not specifically designed to serve as travelways. • Install barricades or warning signs at all approaches to areas where safety hazards exist that are not immediately obvious.

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