Question 7 of 7: Accident Case Analysis — Millwright Ladder Fall
Nivaar worked solution (AI-drafted; not reviewed by a licensed engineer)
Notes on this paper
National Exams — December 2018 — 11-CS-2 Engineering in Society: Health and Safety. Closed book; approved calculator permitted. Any five of the seven questions constitute a complete paper; all questions are of equal value. Answers are written in point form but fully, as instructed. Complete answers to all seven questions follow.
Question 7: Accident Case Analysis — Millwright Ladder Fall (20 marks: 7/7/6)
Immediate cause — the millwright overreached from a ladder (lost balance) while adjusting the flywheel chain in place, and fell onto the shaft, then the conveyor, then the floor.
Root/contributing causes (multiple-factor):
Machine not locked out — the adjustment was attempted with the press still set up to run, rather than shut down, de-energized and locked out. (The paper does not say the press was running; the $5,000 of damage to the shaft and belts is consistent with stored or live energy in the drive, and in any case the flywheel, chain and shaft are hazardous energy that lockout/tagout exists to isolate before any adjustment. State the assumption, as the exam's own instruction 1 invites.)
Improper access/work platform — using a ladder for a task requiring reach and both hands; overreaching beyond safe limits; no stable work platform/scaffold and no fall protection at height.
Procedure/training — no safe procedure for the adjustment; inadequate training/supervision.
Guarding — exposed shaft/moving parts and conveyor in the fall path (the broken conveyor guard suggests guarding issues).
(ii) Corrective Actions
Lockout/tagout before any adjustment. Proper access — stable platform/scaffold or properly secured ladder; prohibit overreaching (body within the side rails); fall protection where required. Safe procedure and training; ensure shafts, flywheel, chain and conveyor are properly guarded.
(iii) Follow-Up
Investigate and document (root-cause analysis); report as legally required; implement corrective actions; write/update the safe-work and LOTO procedures; retrain; audit LOTO/access/guarding; inspect similar tasks plant-wide; repair damaged equipment/guards; monitor for recurrence; support the injured worker; share lessons learned.
