On July 5, 1985, a 27-year-old sewer worker entered an underground pumping station (8' x 8' x 7') via a fixed ladderinside a three-foot diameter shaft. Although this was clearly a confined space, it was not marked as a designatedconfined space. Because the work crew had worked in the area several times without issues, they felt comfortable that they would be ableto complete this task and could later meet the other crew at a bar for drinks after work. They were unaware that there wasa procedure in place to isolate the work area and ensure that the pump had been bypassed. Thus, the transfer line thatthe worker was going to repair was still under pressure. As the worker began to remove the bolts, he noted some sewage coming from the bolt but continued on, as he did notwant his co-workers to ridicule his apprehension. When the workers removed the bolts from an inspection plate that covered a check valve, the force of the waste waterblew the inspection plate off, which allowed sewage to flood the chamber and trap one of the workers nearby. A co-worker, a supervisor, and a policeman attempted a rescue, and all three died. The first two deaths appeared to bedue to drowning, and the latter two appeared to be due to asphyxiation as a result of inhalation of "sewer gas."
Write a detailed report that you intend to discuss before an accident review board that answers the following questions:
·How could Job Safety Analysis have useful?
·What is the root cause of this accident?
·What are the contributing factors in this accident?
·Which events and causal factors analysis from chapter seven of the textbook would you apply? Why? ·What are your recommendations for corrective actions?