Question: Which factor, if not present, could have prevented the accident? An employee ( electrician ) is working on a ladder inspecting an overhead bank of

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?

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