Safety Investigation: Unsecured Plywood Incident

This document details the safety investigation and root cause analysis following an incident where a worker was injured by unsecured plywood dislodged from a roof due to wind. It outlines the hazard identification process, risk assessment, and preventative measures to avoid similar incidents in the future.

Incident Overview

A worker sustained injuries after being struck by unsecured plywood that was dislodged from a roof due to wind. The incident occurred during [Specific Task/Operation, if known].

Investigation Process

The investigation process includes several key steps to determine the root cause and implement preventative measures:

Immediate Reporting: All accidents resulting in worker injury must be immediately reported.
Incident Investigation Team: Assemble a multi-disciplinary team trained in incident investigation techniques, including witness interviews, documentation, and report writing. Employee cooperation is essential, focusing on facts, not blame.
Data Collection: Gather all relevant data, including witness statements, site conditions, weather reports, and plywood securing methods.
Root Cause Analysis: Analyze the data to identify the underlying causes of the incident.
Corrective Actions: Develop and implement corrective actions to prevent recurrence.
Review and Revise: Review the safety plan to determine if additional practices, procedures, or training are needed.
Documentation: Document all findings, corrective actions, and plan revisions.

Hazard Identification

The following hazards were identified as contributing factors to the incident:

Unsecured Materials: Plywood and other materials on the roof were not adequately secured against wind forces.
Wind Conditions: High winds created a foreseeable hazard that was not adequately addressed.
Lack of Inspection: Absence of regular inspections to ensure materials are properly secured.
Work at Height: Working at height increases the risk of falling objects causing injury.

Risk Assessment

A risk assessment was conducted to evaluate the likelihood and severity of the identified hazards:

Unsecured Materials Risk Assessment

Likelihood: High, given the frequency of wind gusts and the potential for materials to become dislodged.
Severity: Moderate to severe, as being struck by dislodged plywood can cause significant injuries.
Risk Level: High

Wind Conditions Risk Assessment

Likelihood: Medium to High, depending on the geographical location and time of year.
Severity: Moderate to severe, as high winds can dislodge unsecured materials and create unsafe working conditions.
Risk Level: Medium to High

Lack of Inspection Risk Assessment

Likelihood: High, if inspections are not regularly conducted.
Severity: Moderate, as failure to identify and correct unsecured materials can lead to incidents.
Risk Level: Medium

Work at Height Risk Assessment

Likelihood: Continuous, as work is performed at height.
Severity: Moderate to severe, as falling objects can cause significant injuries.
Risk Level: Medium to High

Preventative Measures

The following preventative measures are to be implemented to mitigate the identified risks:

Material Securing Procedures

Secure all materials: All plywood and other materials stored on roofs or at height must be secured to prevent dislodgement by wind or other factors. This includes using appropriate tie-downs, straps, or other securing methods.
Material placement: Supplies or materials shall not be placed or stored within six (6) feet of the roof edge.

Regular Inspections

Conduct routine inspections: Implement a schedule of regular inspections to identify and correct any unsecured materials or other potential hazards.
Pre-work checks: Before commencing work each day, conduct a pre-work check to ensure all materials are properly secured.

Weather Monitoring

Monitor weather conditions: Continuously monitor weather forecasts for high winds or other adverse conditions.
Suspend operations: Suspend work operations when wind speeds exceed safe limits. Establish clear guidelines for when work should be halted due to weather conditions.

Fall Protection Measures

Use of fall protection: Ensure all workers at height use appropriate fall protection measures, such as personal fall arrest systems (PFAS), guardrails, or safety nets.
Training: Provide comprehensive training on the proper use of fall protection equipment and safe work practices at height.

Training and Communication

Safety meetings: Conduct regular safety meetings to discuss potential hazards and reinforce safe work practices.
Toolbox talks: Implement toolbox talks to address specific hazards related to the task at hand.
Communicate hazards: Ensure all workers are aware of the potential hazards and the preventative measures in place.

Emergency Preparedness

Emergency action plan: Establish and maintain an emergency action plan that outlines procedures for responding to incidents, including medical emergencies and evacuations.
First aid: Ensure that first aid is readily available on-site, and that workers are trained in basic first aid procedures.

Plan Review and Updates

This safety plan will be reviewed regularly and updated as needed to reflect changes in work practices, equipment, or regulations. Any changes to this plan will be approved by a qualified person. All employees shall be notified and trained in the new procedures. A copy of this plan and all approved changes shall be maintained at the jobsite. [1]

Incident Investigation Procedures

In the event of any accident or near-miss, a thorough investigation will be conducted to determine the root cause and prevent recurrence. The investigation will include:

Immediate reporting: All accidents that result in injury to workers, regardless of their nature, shall be immediately reported.
Team formation: A multi-disciplinary team will be assembled to investigate the incident.
Data collection: All relevant data will be collected, including witness statements, site conditions, and equipment involved.
Root cause analysis: The team will analyze the data to identify the underlying causes of the incident.
Corrective actions: Develop and implement corrective actions to prevent recurrence.
Documentation: All findings, corrective actions, and plan revisions will be documented.

Constant awareness of and respect for hazards and compliance with all safety rules are considered conditions of employment. Failure to follow safety guidelines may result in disciplinary action, including termination. [1] [4]

Reporting and Recording

All fatalities and catastrophes will be thoroughly investigated in an attempt to determine the cause of the event and any effect the violation had on the incident. Each Regional Administrator will establish a procedure to ensure that each fatality or catastrophe is thoroughly investigated and processed in accordance with established policy. [2]

Contacting Family Members

Family members of employees involved in fatal or catastrophic occupational injuries or illnesses shall be contacted early in the investigation and given the opportunity to discuss the circumstances of the injury or illness. OSHA staff contacting family members must exercise tact and good judgment in their discussions. [3]