|Exploration No.:||11111||Accident Date:||22-09-2017|
|DETAILS OF PERSONS EXPLORING THE ACCIDENT|
|Team Leader Name||John Smith||Position||Project Safety Manager||Contact No.||555-1234|
|Team Leader Name||Peter Parker||Position||Senior Safety Advisor||Contact No.||555-2345|
|BASIC ACCIDENT DETAILS|
|Accident Date (dd/mm/yy)||22-09-2017||Accident Time (24 h)||09:00 a.m.|
|Accident Site Address||London|
|Location of Accident on Site||Brine Concentrator 1|
|Person Responsible for Workplace||Mark Masterson|
|Step 1: Accident Level Classification|
|Actual Injury||The class of actual injury was—Nil|
|Potential Injury||The maximum reasonable potential class of injury was—High|
|STEP 2: Observation/Information Gathering|
|Instructions for Gathering Information|
Our first priority is to understand the incident and how the damage was sustained.
Collect related documentation which can compare work planned vs work done—Attach additional material as appropriate such as POWRA, RAMS, Risk Assessments, induction records, toolbox talks, DABs, H&S committee minutes, subcontractor/client incident report, relevant design documentation, operator’s manuals.
Conduct Discovery Sessions with the team involved—Include witnesses/supervisors/experts.
Analyse the accident scene—Take measurements (do not guess), photos, videos, drawings, diagrams/sketches.
|List of Persons Involved (Full name and contact phone number)|
|Name||Contact Phone||Position||Employer||Witness||Statement Attached|
|Jim Johnson||555-3456||Mechanical Fitter||Perfect Construction Ltd.||⊠||☐||⊠||☐|
|Ben Benson||555-4567||Mechanical Fitter||Perfect Construction Ltd.||⊠||☐||⊠||☐|
|Lionel Leslie||555-5678||Cladding Specialist||Superior Insulation||⊠||☐||⊠||☐|
|Mike Michaels||555-6789||Mechanical Supervisor||Perfect Construction Ltd.||☐||⊠||⊠||☐|
|Clive Conlan||555-8901||Scaffold Working Supervisor||Perfect Construction Ltd.||☐||⊠||⊠||☐|
|STEP 3: Give a DETAILED DESCRIPTION of the accident|
| On Friday the 23rd of September 2017, the door of a Brine Concentrator was being secured with nuts when an accident occurred where the tool being used, a torque multiplier weighing 3.8 kg, slipped from the nut it was being used to tighten and fell through a gap in the scaffold deck onto a level 16 m below, where a team on insulators were carrying out works.|
Below are the accounts of those involved:
Jim Johnson—Mechanical Fitter
At our morning briefing, Mike, our supervisor, tasked Ben and I with helping Steve from UK Gas Ltd. carry out an inspection of the inside of Brine Concentrator (BC) 1 prior to its top entrance being sealed. Steve, who was also attending our briefing, said that he would meet us at the BC 1 gate at around 08:30 a.m. Apparently Mike also told us at the briefing about Superior Insulation also working on BC1 on a lower level than us but I definitely didn’t hear that. In saying that, that doesn’t mean he didn’t say as it wouldn’t be the first time we didn’t hear some of Mike’s announcements due to that stupid generator running right behind our briefing area.
Brine concentrator 1.
| Once the briefing was over, Ben and I headed over to the stores to get the gear we needed to carry out the job. We were only able to get the ½ inch drive torque wrench from Al the store man as all of the torque multipliers were in the field. Really and truly, what we really needed was a ¾ inch drive torque wrench for this kind of job as this would have meant not having to use a heavy and awkward torque multiplier at height. Unfortunately, when we asked about buying some, Mike told us that the financial problems faced by the project meant that there was a freeze on buying any new equipment which meant we just had to make do with what we had.|
Without the torque multiplier, there was no way of doing the job but luckily enough I knew one of the guys who had one out from the stores.
| Ben and I headed over to the BC1 gate to drop off the torque wrench at the base. While there, we also carried out our Point of Work Risk Assessment (POWRA) to get it out of the way. I then headed off to the Main Process Building (MPB) to borrow the torque multiplier for the job while Ben headed to the Lime Silo area as he had left his tool lanyards down there the day before when we were down there installing the internal hopper.|
By the time we both got back to BC1, Steve from UK Gas was waiting on us at the gate. Before entering, we were required to gain permission from the area owner, who at the time was Justin James, the Scaffold Superintendent. Justin being the area owner, created 2 problems: As per usual, we got no response from Justin. Instead, we called Clive Conlan, his 2nd in command, who came over quickly and signed us into the area. He didn’t seem to really care what our task was as he himself was fairly loaded with works on the other BCs, where the scaffold systems had yet to be finished and were behind schedule. Steve, Ben and I headed up the scaffold to the upper BC door.
Steve, armed with a torch, stepped into the vessel and carried out his inspection. After giving us the thumbs up, Steve headed off back down the scaffold stairs. We were glad to get the inspection out of the way as it was a BC1 hold point and we were already a week behind program already and the milestone only round the corner in November.
With Steve now gone, Ben and I gave the POWRA a final look to ensure we didn’t miss anything we could be pinged for afterwards. We did write down the use of rubber mats to prevent dropped objects but the problem we had was the site bought cheap mats which are useless in preventing a dropped object because they don’t have the metal rings that the good ones have which allow you to connect them to a railing. Anything that hits the site mats just falls through as the mat isn’t secured.
To be honest, on any other job I’ve been on that has a lot of working at heights on a scaffold, the scaffold is usually fully insulated with netting to prevent anything from dropping.
We then pushed the door of the BC shut and set up our work area, with the tools well away from the gaps in the scaffold. We first placed all of the nuts on the door bolts. This was a job that we had to be really careful with as one slip of the finger could have meant a nut dropping to the floors below.
Brine concentrator door.
| Once all the nuts were on and numbered correctly, we moving to the torque phase. I was lead and Ben was support. Ben handed me the torque multiplier and I placed it carefully on the bolt number 1. I never even noticed that it didn’t have a lanyard attached. Ben then handed me the torque wrench but as he did, my other arm made contact with torque multiplier and it slipped from the nut and fell below. I froze for a second while Ben ran down the scaffold to see where it landed. After a few seconds I came to my senses when I heard shouting from below.|
Work area with visible gaps.
| I ran down the scaffold stairs and found Ben 6–7 floors below talking to the Superior Insulation guys who looked in shock. The torque multiplier had landed only yards from where they were working but luckily no one was hurt. I apologies profusely for my mistake to the guys. I then called Mike and told him about the accident. Mike arrived a few minutes later and secured the scene before calling John, the Safety Manager. Once John came, Ben and I were sent for D and A tests and sat in a room waiting on you.|
Damage to brine concentrator—post-impact.
|Ben Benson—Mechanical Fitter|
We started off our day at our morning briefing with Mike, our supervisor. Jim and I were given the task of babysitting Steve from UK Gas while he inspected the inside of BC1. We were then to immediately secure the door and torque the bolts. The issue we immediately saw was the bolts on the door needed a ½ inch drive torque wrench but we only had ¾ inch drive torque wrenches. The reason for this was because site refused to buy them due to additional costs and the current buying freeze due the project loosing shit loads of money.
We met Steve from UK Gas after the briefing and we agreed to meet at the BC1 access gate at 08:30 a.m.
We then headed off to the stores to get our torque wrench and a torque multiplier. When we got there, Al the store man told us that he was all out of torque multipliers but he had the ¾ inch torque wrench. Luckily, Jim knew that Mark in the MPB had one and, since Mark owed him a few favours by now, he would use this to cash one in. I didn’t bother getting any tool lanyards from Al as the quality of his were poor and my own, which were in the Lime Silo area, were much more suitable for holding a 4 kg tool in place.
When we had gotten what we needed from Al, we walked back to the BC1 gate and dropped off the torque wrench and wrote up our POWRA for the planned job. Jim then headed towards the MPB to collect his torque multiplier while I headed to the Lime Silos to collect my tool lanyards.
While down at the Silos I also saw the rubber mats I had used for the job we had done there the day before on the hopper. I didn’t bother bringing them with me as they were useless in stopping anything from dropping as they had no way of securing them to anything.
Jim and I reconvened at the BC1 gate where Steve from UK Gas was now waiting for us. We tried calling Justin, the area owner, but as usual he didn’t answer. Jim then called Clive, his blue hat, and he came over and allowed us in. The usual protocol is for the area owner to walk out the task with the guys before authorizing but poor Clive clearly didn’t have time for this as his scaffold team was behind. The milestone targets that were agreed for these BCs were ridiculous which meant that everybody was chasing their tail trying to hit dates they never agreed to in the first place.
Jim and I, with our tools with us, headed up the scaffold with Steve. We walked past Superior Insulation but at the time I never even noticed that they were there.
Once we reached the BC door, Steve gave the inside of the BC a swift inspection before giving us the thumbs up and heading off. As always, we gave the POWRA a quick once over to ensure we hadn’t missed anything that could be used against us later. In hindsight, I probably should have removed the rubber mats from it but it didn’t cross my mind at the time.
We set up our work space so that there was minimal movement for us to do. We were well aware of the gaps in the scaffold so we had to keep all of our gear well away from these. Instead of leaving the bucket of nuts under Jim while he placed them, we kept them beside me behind him and I handed them to him. A bucket of nuts falling through a gap can cause a lot of damage!
When all the nuts were placed and numbered, Jim asked me to hand him the torque multiplier. I instinctively reached for it and handed to him. He carefully placed it on bolt number 1 before reaching back for the torque wrench I was about to hand him. It was then I heard a noise and Jim said “oh shit”. I looked to where the multiplier was and all that was left was the bolt and nut and then we heard a bang. My first thought was, “I forgot to put the lanyard on the multiplier.” The only reason I can think of that caused this was fatigue. Due to manpower shortages, I worked through my last R&R and Friday was my 19th day straight on site and these 12 h days take their toll.
I instinctively ran down the stairs and about 7 rows down I found the tool lying beside the Superior Insulation guys, who up until that point, I didn’t even know were there. They were both quite ashen faced and when I asked them if they were ok, all I got was a mumble. I looked around at the BC and saw a big dent where the tool had made contact.
Jim came down after me and when he saw the Superior Insulation guys he apologized profusely. He then rang Mike to come down.
When Mike arrived, he had a look at what happened and had a quick chat with the insulation guys to ensure they were ok. He then rang John, the Safety Mgr., to come down and have a look. When John arrived, Jim and I were sent for D and A.
Mike Michaels—Works Supervisor
As usual, we started off with our morning brief. I gave all the boys their tasks and I asked if there were any issues from the previous day. The only issue raised was the noise of the generator behind us and how it made it difficult to hear what I was saying. Unfortunately, this was the only area we could use for the briefing and the generator was required to run 24/7 to power the welfare facilities.
I then ran through the areas where there was specific risk. One of them was the Superior Insulation boys working a few floors under Jim and Ben.
After the briefing was over, I headed over to the induction room to meet my 2 new starters. We’re under manned at the moment and I’m finding it impossible to hit the targets set by Project Controls, (none of whom have ever built a treatment plant). The new starters were badly needed but it meant half my day was going to be taken up with getting them the basics so they could work onsite.
I got a phone call around 9 a.m. about the accident. I went over straight away to see how bad it was. When I arrived, I saw that it was pretty bad. Jim’s torque multiplier had fallen through a scaffold gap and landed 8 floors below near the Superior Insulation guys.
When I saw what had happened and how it had happened, I was angry.
The original design of the scaffold structure included the requirement for the scaffold to be fully meshed and with drop nets to cover the gap between the scaffold and the BC. This never got done because the scaffold team is under resourced and they were told to move to BC2 as soon as the basic scaffold structure was erected to ensure we hit the milestone. The milestone is the 1st of November and if we don’t hit it, the project loses out on £20 million.
The tool which dropped should never have had to be used either. You only have to use a multiplier when the torque wrench being used doesn’t suit the bolt being torqued. The boys asked me for ½ inch drive torque wrenches months ago but when I put in the purchase order, it was rejected because our corporate commercial team had put a freeze on the ordering off new equipment due to the money being lost on the project.
After a chat with the insulation boys to see if they were ok, I rang John Smith, the Safety Mgr. and told him what had happened. He came down shortly afterwards and assessed the area. He then sent Jim and Ben away for D and A while I rang Mark, the Project Director and told him the bad news and that his BC works would be delayed.
Lionel Leslie—Cladding Specialist
I attended Mike’s morning briefing and listened as he allocated his team their tasks. I didn’t really hear much of what he was saying as the generator beside us is extremely noisy and smothers a lot of the conversation. Someone told me after the accident that he spoke about Jim and Ben working above us but I never heard this; probably because of the noise.
Pete and I grabbed our tools and headed off to BC1. Clive was just at the gate with his own guys and he signed us into the area.
On floor 3, we started carrying out repair work at the back of the BC, with the staircase on the opposite side. We slowly made our way around the vessel. At around 09:00 a.m., we heard a loud bang and a tool bounced off the BC and landed on the scaffold floor beside us. I was in shock as I didn’t know anyone was above us and I hadn’t seen anyone walk by.
After a minute or so of silence, Ben Benson came running down and looked towards the tool. He then began apologizing for what had happened. A minute or so later, Jim Johnson appeared and again began apologizing profusely for what had happened. I couldn’t say much at the time as I was still thinking about how close I had come to being smashed by a tool.
Mike arrived soon after and again asked us if we were ok.
Soon after the Safety Manager came and began asking questions.
Clive Conlan—Scaffold Working Supervisor
I got a call from Jim Johnson at about 08:30 a.m. about getting onto the BC1 scaffold. I was on BC2 at the time and as we are behind schedule and I’m a few men down, I had to rush them through the sign in and didn’t have time to talk them through the other works in the area, which I would normally do. I am not even supposed to be the area owner but my supervisor was unreachable so I got stuck with doing it on the day.
At around 09:30, I heard they had an accident but nobody was hurt. The tool would never have fallen through the gap had we been given time to install the mesh and the nets like we were supposed to. Instead we were rushed over to BC2 to start the scaffold on it. These milestone targets will be the death of someone.
|STEP 4: BASIC LEVEL INCIDENT ANALYSIS|
|1. List Elements|
List the “people”, “equipment”, and “environment” elements involved in the incident
|Jim Johnson||Norbar Torque Wrench Multiplier HT3 3/4||Time||09:00 a.m.|
|Ben Benson||Torque Wrench||Lighting||Good|
|Lionel Leslie||Tool Lanyards||Climate||Warm|
|2. List Factors|
For each element listed above identify essential and contributing factors based on the focussing questions in the left-hand column.
Essential = Factor is essential for damage to occur.
Contributing = Factor increases the likelihood damage occurs but removal may not interrupt incident
|ESSENTIAL AND CONTRIBUTING FACTORS|
|The location of the briefing area next to a generator led to critical information being missed by the work parties.|
|Programme pressures led to essential dropped object prevention systems being omitted from the final design of the BC scaffold structure.|
|A commercial embargo led to an essential tool from being procured and a tool not suitable for the task being used.|
|The £20 million milestone achievement reward created an environment of time and resource constraints due to the creation of an unrealistic target date.|
|Time pressures led to critical information not being communicated during the sign in stage within the BC area.|
|The rubber mats available on site were useless when used to insulate a work area to prevent dropped objects as they had no means of connection to a structure.|
|A failure in the fatigue management system led to a worker being exposed to an excessive work pattern.|
|3. List Recommendations|
From the effectively controllable factors, identified above, list corrective/preventative actions to manage this incident into the future.
|CORRECTIVE/PREVENTATIVE ACTIONS REQUIRED|