Why?

Slips, Trips and Falls: A Root Cause Analysis Primer

Slips, trips and falls happen every day. Falls are responsible for tens of thousands of deaths each year. (Slips and trips are considered a subset of falls, and are included in these numbers.) Falls on the job account for 12-15% of all worker's comp costs. The direct and indirect costs of workers injured and killed on the job are estimated to be billions of dollars each year, both in worker's comp claims and in lost productivity. In 1999, as an example, 5,100 workers were killed by falls and over 570,000 injuries were reported. However, there are many things that can be done to prevent and lessen the impact of falls. Performing a cause map - a visual root cause analysis - will allow us to identify all the potential causes of falls. A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page. Once we've done that, we can identify all the solutions.

A worker is injured during a fall because the worker strikes the floor, or another object, and the object contacted is hard, and the worker hits in a way that causes injury. When I say that workers are injured becauese they hit an object in a way that causes injury, what I am really talking about is factors that worsen a fall, and make injury more likely. The worker could land on a part of his or her body that is more easily injured. Another way that injuries can be worsened is if a worker falls farther than his or her height (i.e., not a same-level fall).

The worker strikes the floor or other object because he or she falls, and there is no other support for the body, such as a handrail, or a harness. There are four different ways to fall: slips, trips, the "step and fall" - where a person gets off-balance while stepping - and becoming unbalanced on moving equipment.

Solutions: Use harness or handrail

Safety Goal Impacted

Worker strikes floor or another

object

No other support for

body

AND

Worker falls

Monetary Goal Impacted

Billions of dollars in worker's comp, lost productivity

5,100 workers k5i,ll1e0d0frwoomrkfearllss killed from falls

AND

Worker injured

AND

Solutions: Use soft floor covering

Surface of floor/object contacted hard

570,000

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AND

Safety Goal Impacted

Worker hits object in a way

that causes

A worker can become off-balance by encountering an

injury

unexpected height difference (known as the "step and fall").

This occurs in one of two ways. Either the front foot lands on a

surface lower than expected, or the ankle turns due to one side

of the foot ending up higher than the other side, with footwear

that inadequately supports the ankle. These are both due to an

unexpected height difference.

Solutions: Tuck in head and land on side

Lands on part of body more easily injured

AND/OR

Solutions: Use harness when working at heights

Worker falls farther than worker's height

Cause Map

Detail Level

Houston Office 281-489-2904

Why?

Effect

Cause

NOTE: Read the Cause Map from left to right with the phrase "Was Caused By" in place of each arrow.

A worker slips when there is inadequate traction, either because the force of stepping off is too high, or the coefficient of friction is too low. The force of stepping off can be higher than average if the worker is walking quickly or running, making a sudden change in direction, or if he or she has an awkward gait, from injury or old age, for example. The coefficient of friction is a function of the traction provided by the shoes the worker is wearing and the "slipperiness" of the walking surface. The coefficient of friction is too low if the traction of the worker's shoes is inadequate and if the floor is slippery, because the surface is wet, icy and/or oily and does not have a non-skid coating. Of course, for this to be an issue at all, the worker has to step into the slippery area.

Awkward gait AND/OR

Force of stepping off too

high

Worker slips

Traction inadequate

AND

AND/OR

When a worker trips, it is because his or her toe is stopped, but his or her upper body is not stopped. The upper body does not stop because the worker is moving (and so is the upper body) and it does not stop due to inertia, or Newton's First Law (a body in motion stays in motion). The toe is topped because it encounters an object in the walking path, a rise in the walking path, or a difference in height of subsequent stairs.

Toe stopped

Coefficient of friction (COF)

too low

Solutions: Ensure walking path properly maintained

Object in walking path

AND/OR

Rise in walking path

Solutions: Ensure walking path properly maintained

Worker steps on slippery area

AND Solutions: Wear shoes with good

Traction provided by

shoes

AND

Quality of walking surface

slippery

Sudden change in direction

AND/OR Solutions: Walk at a medium, even pace

Walking quickly or running

No non-skid floor coating

AND Solutions: Ensure walking path properly

Surface icy

AND/OR

Surface wet

Worker trips

AND

AND/OR

Solutions: Ensure even walking surface

Difference in height of

subsequent steps

AND/OR SolutAioNnDs/O: R Ensure walking path properly maintained

Surface oily

AND/OR

Worker offbalance ("step

and fall")

Upper body not stopped

Front foot lands on surface lower than expected

AND/OR

Ankle turns

Worker moving

AND Inertia

Solutions: Ensure even walking surface

Unexpected height

difference

One side of foot ends up higher than other side

AND Solutions: Wear footwear with ankle support

Footwear inadequately supports ankle

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