Night-Time Fall from a Ladder in a Cold Store
At 21:30 in a food-processing factory, a 52-year-old electrician fell 2.4 m from a fibre-glass stepladder while replacing a ceiling light in a cold store. He suffered a fractured wrist and a scalp laceration; he was alone and was found by a cleaner about 10 minutes later. The ladder's rubber feet are missing, the top rung is cracked, and the floor was wet from a wash-down. There was no permit-to-work for night work and no task-specific risk assessment. The shift supervisor says the electrician was 'experienced but careless'. CCTV covers the corridor but the cold-store doorway blocks the view; the recording shows a 30-second gap. The electrician's training record shows a ladder-safety course completed four years ago. The factory wants to close the case as 'worker error' and give a written warning.
1. Outline your investigation plan and the evidence you would secure in the first 24 hours.
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Scene and equipment: preserve the ladder, the broken light fitting and the electrician's PPE. Photograph the ladder feet, cracked rung, floor condition, lighting level and the position of the fall. Measure the working height and the floor slope. Do not repair or discard the ladder.
Documents: night-shift rota, permit-to-work system, risk assessments, maintenance records for the ladder, training records, cold-store wash-down schedule, CCTV, alarm and access logs, and the electrician's medical report with consent.
People: interview the electrician when medically fit, the cleaner, the supervisor, the previous shift and anyone who saw the ladder before use. Ask open questions: what was the task, what equipment was available, who assigned the work, was the floor wet, was anyone else present.
Timeline: reconstruct the sequence from clock-in to discovery. The 30-second CCTV gap is a limitation, not proof of carelessness; record it as such.
Reasoning: the purpose is to establish what happened and why, not to confirm the supervisor's opinion. Securing physical evidence early prevents loss and allows a causal analysis rather than a blame conclusion.
2. Using a causal analysis, identify likely root causes and contributing factors. Why is 'worker error' inadequate?
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Immediate causes: the ladder had no rubber feet and a cracked top rung; the floor was wet; the electrician worked alone at height.
Contributing factors: no task-specific risk assessment or permit for night work; no ladder inspection before use; inadequate lighting; no safe alternative such as a mobile tower or platform; training four years old and not refreshed; supervision absent at night; production pressure to complete the light replacement.
Root causes: the management system did not control work at height. Ladder inspection and maintenance were not scheduled; the permit system did not cover night work; the risk assessment did not identify the cold-store floor and lone working; and there was no verification that the electrician could work safely without assistance.
Why 'worker error' is inadequate: it describes the last action, not the conditions that made the action likely. A worker using a defective ladder on a wet floor without a permit is a symptom of failed maintenance, planning and supervision. If the investigation stops at 'careless', the ladder remains in service, night work remains unassessed and the next electrician faces the same conditions. Disciplinary action may be appropriate for deliberate breaches, but it cannot substitute for correcting the system.
3. Write the findings and recommendations for the report, and advise on how to handle the proposed written warning.
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Report structure: terms of reference; description of the incident; evidence and timeline; causal analysis; findings against legal duties; recommendations with owners and deadlines; appendices.
Findings: the fall was predictable and preventable. The ladder was defective and had not been inspected; the wet floor was known from the wash-down schedule; lone night work at height was not authorised or supervised; and the risk assessment did not cover the task. The electrician contributed by using the ladder, but the organisation created the conditions.
Recommendations: remove defective ladders from service and introduce pre-use checks; provide mobile platforms for ceiling work; extend the permit-to-work system to night work and work at height; add cold-store floor conditions to the assessment; refresh training and supervise night work; investigate near misses; review the procurement and maintenance of access equipment.
The proposed warning: advise that disciplinary action should not be decided until the investigation is complete and the electrician has had the opportunity to respond. A written warning based on 'careless' would be unfair if the ladder was known to be defective and no safe system was provided. If there was a deliberate breach, handle it through a separate fair process. Record the rationale. This protects the worker and the company and avoids a decision that a regulator or court could later find was predetermined.