1. Learn from a fatal error 1 Work Stoppage 26 February 2001 “Learn from a Fatal Error ” 1

2. Learn from a fatal error 2 Mr Tek Bahadur Gurung Died on 16/Feb/2001 He was just loading some pipes on a truck WHY did he die? What will YOU learn from his death? 2

3. Learn from a fatal error 3 A foreman and 2 crew were manually loading this canter truck with 6 m long 6” plastic pipe joints. To gain space every joint was filled with three 2 inch pipes. This made each section quite heavy: approx 70 kg. 3

4. Learn from a fatal error 4 Discuss with your team: Your task is to load these pipes. A simple job! Isn’t it ??? How would you do this? Would you just start and see how it goes? Would you think about it first? Would you discuss your plan with the team? What could be the possible hazards/risk? What could go wrong? What if? How would you ensure all team members understand the hazards and the controls? 4

5. Learn from a fatal error 5 The real questions is: The real questions is: Would you a have a tool-box meeting for what seems to be a simple and routine task ???? Yes! Yes! Good! Make this a standard practice for every task! Find hazards BEFORE you start. No! No! Better think again. You are putting yourself and your team at risk! See what went wrong here! 5

6. Learn from a fatal error 6 The foreman was standing in the truck directing his 2 crew. 7 joints had been loaded. The crew were adding no 8 from the back of the truck. What could go wrong here ?? 6

7. Learn from a fatal error 7 The pipes were forced apart. The last joint pushed the foreman back. He fell to the ground. The pipe also. The stopper was too low!! No one had thought about this hazard. Too Low !! Too close to the edge!! 7

8. Learn from a fatal error 8 He fell flat on his back. His helmet came off. His head probably hit a stone. He died on the spot from the head-injury. 8

9. Learn from a fatal error 9 Discuss with your team: Now that you know what happened, why did it? What were the basic errors made by this team? Does your team discuss the possible hazards each time you start a simple task? What simple tasks does your team do every day? Make a short list of them. Do you even think about the possible hazards? Take one of these tasks and discuss it now: try and find the hazards. How do you control them? 9

10. Learn from a fatal error 10 What can you learn from this specific accident: Check support frames on trucks: stoppers must be high enough to block the loads. Never ever stand on a truck while it is being loaded (manually or with a crane). Loads move and can push you off or crush you. BUT the main thing is: Before starting any task/job (even simple ones!): HAVE a Toolbox talk/meeting Find the hazards BEFORE they find YOU 10