Time Out For Safety

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Time Out For Safety

• BSP/BLNG
• 25th August 2004
• BSRC Ball room

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This gentleman would have celebrated his 31st
birthday on 25th August BUT..
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Fatality Incident on 18 Aug 2004
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SEQUENCE OF EVENT


CG

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12/08/04

13/08/04

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32 T SPOOL


11/08/04
Primary Support


(WEDNESDAY)


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16/08/04 UNTIL
16/08/04 UNTIL
1600HRS

1600HRS




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PICTORIAL REPRESENTATION
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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.

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Fatality Incident on 18 Aug 2004

• 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

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Fatality Incident on 18 Aug 2004

• 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.

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Fatality Incident on 18 Aug 2004

• 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

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Findings

• Direct Causes
• 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.
• For unknown reasons, the deceased attempted to
  sit on the vertical flange of the Tee piece
• This action caused the unstable Tee piece to slip
  and topple over.
• The deceased suffered severe head injuries after
  being crushed by the Tee piece.

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Findings

• Indirect Causes (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.
• Although a co-worker, recognising a hazard,
  re-secured the Tee piece on a chain block, this
  was subsequently removed.
• The instability of the Tee piece had not been
  communicated to the others. Enforcement of Duty
  to Stop was inadequate.
• General lack of hazard awareness of the
  workforce.
• Hazard Identification Plan (HIP) for the
  contractor fabrication yard was not developed.
• Lack of barricades and warning signs around
  hazardous areas.
• No designated rest area

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Findings

• Indirect Causes (2)
• Lack of effective supervision.
• Lack of planning Work started on the Tee piece
  before all the materials had arrived.
• 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.

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Immediate Action (1)

• Please undertake the following
• Survey work supports at all worksites
  immediately. Rectify where work supports are
  unsafe or inadequate. Communicate any unsafe
  conditions found.
• Ensure you have a HIP for every stage of your
  project, including the fabrication stage, both at
  BSP and the contractor worksites.
• Include HIP in Tool Box Talk. Address safety of
  worksites, even when unattended.
• Ensure provision and enforce use of designated
  rest areas at worksites.

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Immediate Action (2)

• Please undertake the following
• 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?
• Confirm who is responsible for sub-contractor HSE
  management.

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Areas requiring further work

• We will need to strengthen the culture of
  intervention (e.g. PAKAT, House Rules,
  Consequence Management).
• 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.
• We will require contract holders to include all
  direct and indirect sub contractors in HSE
  performance reviews.
• Review appropriateness of contracting strategy to
  ensure HSE responsibilities can be effectively
  exercised.