Continuing our discussion on accidents and root cause analysis, I would like to offer you a practical exercise.
When I was taking the "Incident Investigation" training course, we were given a case study to review, analyze, and determine the causes of the accident to reinforce our practical skills.
I invite you to apply your knowledge and analyze it yourself. At the end of this post, I have included my own analysis of the case for you to review and compare.
Study the case and determine the immediate, underlying, and root causes.
Romashka LLC was negotiating a lucrative contract with a large corporation, Vostorg. Securing this contract was extremely important for the company — it would significantly increase revenue and allow for a long-overdue office renovation.
A few weeks ago, an employee tripped on a worn carpet on the main office staircase. Fortunately, he was holding the handrail — a company requirement when using any stairs in the building. The incident was reported to the manager, Sergey Ivanovich Ivanov.
However, Sergey Ivanovich was under severe stress due to the need to close the deal with Vostorg Corporation. Since no one was injured, he took no further action. After all, in his opinion, if replacing the carpet was included in the office renovation plan after the contract was signed, the problem would resolve itself.
The negotiations took several weeks, and the contract was eventually signed, although the deadlines for delivery and technology implementation turned out to be extremely tight. Intense work began at Romashka LLC, and to meet the schedule, Sergey Ivanovich constantly asked employees to stay late and work overtime.
His assistant was a new employee, Zhanna. She had started working just a month ago. He had no time for a comprehensive HSE induction and workplace safety briefing, which, according to regulations, should have been conducted in her first week. Instead, he had a brief chat with her and promised to hand over a copy of the internal rules as soon as he found them. At the same time, he failed to mention two important company rules: always holding the handrail on the stairs and the ban on using personal mobile phones during working hours.
Zhanna gladly agreed to overtime — she was planning her wedding this year and needed the money. Sergey Ivanovich noticed that she frequently used her phone to discuss personal matters, but he didn't attach any importance to it: most employees, including himself, also regularly used personal devices at work, despite the company rule.
At 6:15 PM on April 11, Zhanna urgently needed to call a florist to discuss a bouquet. At that moment, Sergey Ivanovich asked her to take some documents to the accounting department on the first floor. Zhanna decided to combine the tasks and make the call on the way. Walking down the stairs, she held a stack of papers in one hand and her mobile phone in the other. She didn't notice her heel catching on a hole in the carpet. The young woman lost her balance and tumbled down the stairs. She was taken to the hospital, where she was diagnosed with a broken leg and a dislocation.