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?

$1.$ What Root Cause analysis technique they will use to analyze the scenario $(5$ why, Ishikawa, etc.$).$ Be prepared to explain why you chose that particular method.

$2.$ What information you are missing to aid in determining a root cause. Make a list of any pertinent information lacking in the details provided.

$3.$ What is$/$are the root cause$($s$)$ of the incident based on their analysis. Groups will also be asked to detail underlying or immediate causes relevant to the incident that go hand in hand with the root cause$($s$).$