Lessons Learned: Step-ladder Failure (LTI)

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An IMCA report states that a crew member fell from the top step of a small folding stepladder while working.

What happened?

A crew member was working while stood on the top step of a small folding stepladder when the step gave way, causing the crew member to fall to the ground. The impact resulted in back and head injuries, leading to a brief loss of consciousness and severe back pain. After medical attention on board, the crew member was deemed to be unfit for work for 72 hours. The crew member was subsequently transferred to hospital for further comprehensive medical evaluation.

What went wrong?

Investigation established that the incident was caused by the failure of the welds securing the stepladder’s top step supporting rod to the frame.

MAIB considered it unlikely that the weight of the crew member would have been sufficient to cause the catastrophic failure of a metal support on a new stepladder. The stepladder used in this incident was of an indeterminate age but was not being overloaded so it is almost certain that the damage to the metal support was pre-existing.

Lessons learned

  • Check and inspect equipment thoroughly before use. Work equipment should also be maintained in good repair and, where applicable, with maintenance and inspection logs kept up‑to‑date.
  • Accidental damage to equipment can sometimes occur. A just culture working environment balances fairness, learning and shared accountability and supports staff to adopt an open and honest approach to reporting incidents. Where damaged equipment could affect the next user, a just culture is essential to understand why the failure occurred and how to prevent it happening again.

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Source: IMCA