BSP/Contractor fatality Incident Investigation Slide: 1 Time Out For Safety BSP/BLNG 25 th August...

BSP/Contractor fatality Incident Investigation Slide: 1

Time Out For Safety

BSP/BLNG

25th August 2004

BSRC Ball room


This gentleman would have celebrated

his 31st birthday on 25th August BUT………..


Fatality Incident on 18 Aug 2004


1

11/08/04

(WEDNESDAY)

CG

SEQUENCE OF EVENT

Primary Support

32” T SPOOL

CG

4

16/08/04 UNTIL

16:00HRS

3

16/08/04 UNTIL

16:00HRS

5 Tons JACK

2

12/08/04 – 13/08/04


PICTORIAL REPRESENTATION


Tee-Piece Fabrication Fatality Time Out25 Aug 2004

Purpose To share preliminary findings of the investigation. Cascade immediately the preliminary findings to all

BSP staff and contractors within the next 48 hours Implement immediate actions recommended by the

investigation team to prevent recurrence

Note that this is only the beginning and there are many more areas that we need to work on in more detail.


Incident Details:• At Zainal Daud (ZD) Fabrication Yard (G25) at 7.30 a.m.• Victim: Mr. Lee, 31 years old Malaysian working for Chin Wui

Heng Welder Enterprise • Occupation : Senior Marker, 8 yrs experience• Injury: Death from severe head injuries.• Survived by: Spouse & 4 years old son.• Project: Single Buoy Mooring (SBM) Metering (Phase 2)• Main Contractor : Warner & Company Sdn. Bhd.

• Sub-contractor: Zainal Daud Sdn. Bhd.• Sub sub-contractor: Chin Wui Heng Welder Enterprise



Facts & Findings (1) :• Fabrication Yard Work delayed whilst waiting for Tool Box Talk• 32” pipe Tee piece 300 # (1.3 tons) partially completed (2

flanges welded on). Suspended, awaiting material.• Was supported by 2 primary ground supports.• Chain block and 5 tons jack were used whilst fabrication was in

progress for alignment purposes. • Chain block and jack were removed after welding of 2 flanges.• No further adjustments of the primary supports were made to

improve stability.• Deceased was assigned the role of supervisor of the above

fabrication activities.



Facts & Findings (2):• Initial calculations indicate Tee-piece Centre of Gravity shifted

significantly & effectively on the verge of tilting.• Since materials were not available, no further work was carried

out. Two days later, the deceased (ca. 70 Kg wt) attempted to sit on outer rim of Tee-piece flange.

• Tee piece slipped & toppled over crushing victim on the head



Findings

Direct Causes1. The Tee piece became unstable after the installation of the

two flanges. The centre of gravity had shifted but the primary supports were not adjusted.

2. For unknown reasons, the deceased attempted to sit on the vertical flange of the Tee piece

3. This action caused the unstable Tee piece to slip and topple over.

4. The deceased suffered severe head injuries after being crushed by the Tee piece.


FindingsIndirect Causes (1)

1. The A-Frame, chain block and 5 Tons jack used earlier for alignment purposes were removed leaving the Tee piece on the two unadjusted ground supports.

2. Although a co-worker, recognising a hazard, re-secured the Tee piece on a chain block, this was subsequently removed.

3. The instability of the Tee piece had not been communicated to the others. Enforcement of Duty to Stop was inadequate.

4. General lack of hazard awareness of the workforce.5. Hazard Identification Plan (HIP) for the contractor fabrication

yard was not developed.6. Lack of barricades and warning signs around hazardous

areas.7. No designated rest area


Findings

Indirect Causes (2)8. Lack of effective supervision. 9. Lack of planning: Work started on the Tee piece before all the

materials had arrived.10.Contract HSE Management:

• Lack of clarity between contractor, sub-contractor & sub-sub-contractor on responsibility for HSE management

• The main contractor was required under its contract with BSP to play a leading role in HSE implementation, not just the subcontractor

• There were early warning signs of a lack of commitment to safety such as not following up on repeated violations identified during site visits.


Immediate Action (1)

Please undertake the following:

1. Survey work supports at all worksites immediately. Rectify where work supports are unsafe or inadequate. Communicate any unsafe conditions found.

2. Ensure you have a HIP for every stage of your project, including the fabrication stage, both at BSP and the contractor worksites.

3. Include HIP in Tool Box Talk. Address safety of worksites, even when unattended.

4. Ensure provision and enforce use of designated rest areas at worksites.


Immediate Action (2)

Please undertake the following :

5.Supervisors & contract holders/managers accountability for safety:– Do you know the full extent of your role?– Do you know what you are accountable for? – Are you discharging your responsibility?

6.Confirm who is responsible for sub-contractor HSE management.


Areas requiring further work

1. We will need to strengthen the culture of intervention (e.g. PAKAT, House Rules, Consequence Management).

2. We will require senior management of all contractors, all direct and indirect sub-contractors to demonstrate commitment to HSE by, for example, site visits and mandatory joint HSE meetings.

3. We will require contract holders to include all direct and indirect sub contractors in HSE performance reviews.

4. Review appropriateness of contracting strategy to ensure HSE responsibilities can be effectively exercised.

BSP/Contractor fatality Incident Investigation Slide: 1 Time Out For Safety BSP/BLNG 25 th August...

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