Checklist completeInvestigation is ready for final review.
Phase 1 — First notification 0/2
Phase 2 — Field collection 0/8
Incident details
INC-2024-0047 · Scaffold collapse, Platform B · June 2, 2026 · Gulf Coast Refinery · High severity
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scene_photo_01.jpg
2.4 MB
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witness_statement_ramos.txt
8 KB
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scaffold_inspection_report.pdf
340 KB
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AI witness statement analyzer
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Witness outreach log
CR
Carlos Ramos
✉ c.ramos@gcrefinery.com
Received
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Tony Walsh
📱 +1 (409) 555-0182
Sent
MB
Maria Bautista
✉ m.bautista@gcrefinery.com
Overdue
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🔴 SIF classification — LIFE Model
⚠ Only make a final determination once all relevant information has been received. Reclassify if new information changes any answer.
1Was an injury sustained?
Injury: sudden physical damage to the body caused by an external force.
2Was it life-ending?
Life-ending: injury resulted in the death of the injured person.
3Was it life-threatening?
A qualified person confirms the injured person would not have survived without immediate medical intervention (CPR, defibrillation, etc.).
4Was it life-altering?
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⚠ PSIF assessment
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PSIF determination basis
This classification is preliminary. Return and reclassify if new information becomes available. Both determinations should be reviewed and signed off by the lead investigator before inclusion in final reports.
Contractor
3 docs
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Scaffold erection & inspection SOP
SOP · PDF
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Fall protection policy
Policy · PDF
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Safety management program 2024
Program · DOCX
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Client documents
Client
2 docs
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Site safety requirements — contractors
Policy · PDF
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Permit to work program
Program · PDF
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AI document cross-reference
AI compares all uploaded documents against the incident facts to identify violations and missed steps.
Reviewing documents against incident evidence...
3
Violations
4
Missed steps
Gulf Coast Safety LLC
Scaffold inspection SOP — flexion test not performedViolation
Scaffold SOP · Section 4.2
SOP Section 4.2 requires a physical flexion test on all scaffold planks prior to erection. Evidence confirms this step was not performed during the pre-shift inspection on June 2, 2026.
SOP review cycle requirement not metViolation
Safety management program · Section 7.1
Program requires annual SOP review. The scaffold inspection SOP was last reviewed in 2019 — a 5-year gap in violation of this requirement.
Pre-task hazard assessment not documentedMissed step
Fall protection policy · Section 2.4
Policy requires a documented pre-task hazard assessment before any work at elevation. No form was found in the evidence for Platform B on June 2, 2026.
Apex Petrochemical
Contractor SOP not approved by clientViolation
Site safety requirements · Section 3.2
Client requires all contractor SOPs to be reviewed and approved by their safety representative before work begins. No approval record was found.
Permit to work — scaffold checklist incompleteMissed step
Permit to work program · Section 6.3
Scaffold permit for Platform B was missing the required inspection checklist attachment.
3
Evidence files
High
Risk rating
✦ AI investigation summary
Analysis of 3 evidence files identified a scaffold plank failure caused by an incomplete inspection protocol. Four systemic contributing factors found across equipment, process, management, and environmental categories.
Select cause map method
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Fishbone
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Swiss cheese
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5-Why
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Multiline
Fishbone — Ishikawa cause & effect
🔍 Root cause summary
Cracked plank not identified during pre-shift inspection
Inspection checklist lacked flexion test requirement
Scaffold SOP last updated 2019 — no review cycle
No formal safety management system for SOP lifecycle
✓ Corrective actions
Remove all cracked scaffold planks from service immediately
Update scaffold inspection SOP to include flexion tests
Implement quarterly SOP review cycle with safety manager sign-off
Retrain all scaffold erectors on revised inspection procedures
✓ Evidence
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✓ SIF/PSIF
✓ SOP review
✓ Analysis
6 Lessons learned
Investigation data available
3
Evidence files
4
Root causes
7
Violations
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Lessons learned — INC-2024-0047
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