Serious Harm – notifiable incidents Duty Holder Review requirements.
The wearer of this boot was run over by a double axle trailer and fractured his fibula and tibula.
I carried out an ICAM (Incident Cause Analysis Method)Investigation, there were many contributing factors including weather and rushing but the causal factors that led to the accident were;-
– Poor supervision of the workers in what was a complex operation.
– Procedures were not followed correctly.
– Drift had been allowed to happen. Drift is when workers normalise short cuts or unacceptable behaviours and the company does not correct it.
– Organisational failures, which included conflicting task expectations. On time performance conflicting with operational chnages.
– One of the employees tested positive to drugs but this was not identified as the main contributing factor.
Worksafe was immediately notified and we carried out a Duty Holder Investigation Report. PCBU and Duty Holders need to be aware of this requirement and the review document. Contact me if you have a query around this issue.
The injured employee returned to work after 9 months but in a limited capacity. He struggled for along time and had issues with the steel rod that was inserted into his leg. His quality of life will never be the same.