A contract engineer visited site to assess a reported defect on a wheeled loader. After completing the required tests and repairs in the workshop, the machine was returned to its operator to ensure it was in working order. However, the contractor realized that an additional check was necessary and requested the machine be brought back to the workshop. By this time, the operator had already parked the machine in the external parking area. The contractor decided to complete the final check there.

With the final check completed, the contractor packed his tools into his van parked nearby and climbed back into the loader's cab to retrieve his keys. Whilst descending to ground level, he twisted his ankle. Believing it to be a minor sprain, he returned to the site office to complete his documentation and prepare to leave. An initial assessment concluded he was safe to drive home. However, a subsequent medical assessment and x-ray revealed that he had sustained a fracture to his ankle.

KEY FINDINGS

Risk assessment - Risk Assessments & Method Statements were supplied prior to the work, and a permit to work was completed by the site team. Additionally, the contractor completed a pre-task risk assessment, but this was not reviewed by the site team.

Experience - The contractor was approved and competent for the work.

Workplace layout/design - The agreed work location changed from the workshop to the external mobile plant parking area, which has slightly uneven ground conditions

HOW COULD THIS HAVE BEEN AVOIDED

• Always ensure you maintain three points of contact when accessing or egressing vehicle steps. Remember, 'GET A GRIP.' Avoid jumping down from steps and never descend facing forward.
• Awareness – take care when ascending or descending vehicle steps to ensure you have a secure footing. Additionally, avoid parking vehicles near puddles or depressions.
• The contractor should have completed all the necessary checks while the machine was in the workshop.
• Effective assessment of work area especially when there are changes in the work location (management of change)
• Communication -  Corden-off work area - the area within the workshop could have been blocked off until the work was complete and/or discussed keeping it free with workshop staff or management.

KEY REVIEW POINTS

• Consider management of change - review permits and risk assessments if there are any significant changes to the task 
• Maintain effective three points of contact – ensure relevant ‘Get a Grip’ signage is displayed and highlight first and last steps where practical
• Review mobile plant parking areas and ensure they are free from hazards.