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6.5 A Case Study to Work Through
A small company, Exciting Technologies, was negotiating a valuable contract with a large multinational. The contract would let it expand and refurbish its worn out offices.
A few weeks earlier a member of staff tripped on a worn section of carpet on the main staircase. She was holding the handrail, which was a company rule, so she was not hurt, and the incident was reported to the office manager, Mr Steel. He was under pressure to win the contract and, since no one was harmed, he took no action. New carpet would come with the refurbishment, and the problem would go away.
The contract was signed, with tight production deadlines. The office became very busy, and Mr Steel kept asking staff to work extra hours while he struggled with the paperwork. Delphine had worked there for a month. Her induction, which should have taken place in the first week, had not happened. Mr Steel had told her in a short chat that she would get a copy of the rules when he found them. He did not tell her that the rules included holding the handrail on stairs and not using personal mobile phones in office hours. Her supervisor often saw her calling wedding suppliers during the day and did not mind, since most staff, including him, used their phones at work.
At 6:15 pm on 1 April Delphine needed to call her wedding planner. Mr Steel asked her to take some overdue papers downstairs. She decided to make the call on the way. She started down the main staircase holding the papers in one hand and the phone in the other. The heel of her shoe caught in the worn carpet, and she fell down the whole flight. She was taken to hospital with a broken ankle and a dislocated foot.
Summary
- You investigate incidents to prevent them happening again, to meet legal requirements and to learn.
- Incidents happen because of immediate causes, underlying causes and root causes, and usually several of each.
- You carry out an investigation by looking after the injured person, preserving the scene, reporting, choosing the team and level, then gathering information, analysing, reviewing controls, planning action and sharing the lessons.
Incident Report Form
| Item | Details |
|---|---|
| Company, department and location | |
| Date and time of the event | |
| Type of event | Injury, ill health, near miss |
| Harm or potential for harm | Fatal or major, serious, minor, damage to property only |
| Person involved | Name, position and contact number |
| Description of the event | What happened, when and where, and the emergency action taken |
| Witnesses | Name, position and contact number |
A study aid, not published or endorsed by IOSH or OSHA. Laws and limits differ between countries.