Which factor, if not present, could have prevented the accident? An employee $($electrician$)$ is working on a ladder inspecting an overhead bank of lights and the ladder collapsed under the employee. The employee falls off the ladder and breaks their arm.

The investigation reveals the following details:

$$ Employee had worked seven $12-$hour shifts in a row.

$$ Accident happened at end of shift.

$$ Employee was standing on the top step of the ladder $($an unsafe action$).$

$$ The employee was approximately $10$ feet above floor level.

$$ No fall arrest or restraint system was used.

$$ A ladder inspection policy is in place, but there is no evidence that the ladder has ever been inspected.

$$ Investigation reveals the ladder was damaged and did not provide a stable working platform in any environment.

$$ Interview with facility manager reveals that he did not inspect the ladder when it was due for inspection. He was aware that ladder needed to be inspected.

$$ Extended work hours may have caused employee to be tired and not clear$-$headed.

$$ Employee violated safety rule $($standing on top step$).$

$$ Ladder was defective and unusable.

$$ Facility manager was aware that ladder needed to be inspected but did not adhere to the existing policies and procedures for ladder inspections.

What is the Root Cause?

This is Accident Scenario number $2$:

A Forklift Operator was driving forwards with a full palletized load on his way from a receiving dock to a storage area. The dock was full and congested making it difficult for him to drive in reverse with a better view of his path of travel. He was travelling in a westerly direction. As he was passing by several storage racks, another forklift operator driving in reverse with a full load on the way to the shipping dock exited the racking system and was struck by the first forklift side$-$on$.$ The second forklift was turning westerly so the operator of forklift #$2$ was not looking at the first forklift on his blind$-$side. The second forklift operator was badly shaken up as he took the brunt of the collision. There was extensive damage to the forklifts and the material being transported.

The investigation revealed the following details:

$$ There is always congestion in the forklift lanes as both receiving and shipping forklifts have to take the same route of travel. There are no demarcations on the floor as to intended paths of travel nor is there an official travel plan for different duties.

$$ There are cornering mirrors at the intersections of the end of aisleways, but not at the end of storage racks.

$$ Both operators were wearing ear muffs

$$ The facility had been over$-$receiving on its orders for two weeks and the receiving dock was at $140\%$ capacity.

$$ Neither forklift had functioning back up alarms or lights. It had been noted on pre$-$shift inspection forms intermittently but not corrected.

$$ Operators alternate between shipping and receiving$/$picking duties on a weekly basis.

$$ The accident occurred $5$ minutes before the lunch break of driver #$1$

$$ Driver #$1$ had been driving for $15$ years and has had $3$ prior incidents

$$ Driver #$2$ had been driving for $1$ year with no incidents

$$ The company$$s forklift driving procedure has a requirement that when approaching blind spots, the end of aisles or at corners, the $$forklift operator must slow down, check blind spots and sound their horn announcing their approach.$$ Driver #$2$ did not do that.

$$ This was a Monday, first shift of the week for both drivers.

What is the Root Cause?

Which factor, if not present, could have prevented the accident?